Can Russia Build a More Integrated Long-Term Care System for an Ageing Population?

For an older person in Russia who begins to lose mobility, the need for long-term care rarely arrives as a single, clearly defined event. It may begin with difficulty shopping or preparing meals, progress to support with washing and dressing, and eventually involve rehabilitation, medication management, supervision or regular assistance from relatives. Each change creates decisions about who should provide support, how it will be funded and whether different services can work together.

Russia has been developing a more systematic response through its Long-Term Care System, known as Sistema dolgovremennogo ukhoda (SDU). The initiative seeks to improve the identification of people requiring continuing assistance and strengthen access to coordinated support, particularly in their own homes. It represents an important direction within the wider development of Russia's social protection arrangements.

As explored through the Russia Ageing, Long-Term Care & Community Support Knowledge Hub, the central challenge is not simply expanding the number of services. It is establishing a dependable relationship between national policy, regional delivery, health care, social services, families and the people whose independence depends upon effective support.

Whether Russia can develop a genuinely integrated long-term care system will depend on how consistently these responsibilities are connected in everyday practice, how regional inequalities are addressed and whether care quality can be demonstrated through meaningful improvements in people's lives.

Russia's ageing population is changing the nature of care demand

Population ageing is reshaping the requirements placed upon Russia's health and social protection systems. Longer periods of life with chronic conditions, reduced mobility, cognitive impairment or functional limitations can generate needs that are neither exclusively medical nor adequately addressed through occasional social assistance.

An older person recovering from a stroke may require clinical rehabilitation, personal assistance, equipment, housing adaptations and support for a family caregiver. Someone living with dementia may need supervision, meaningful activity and help with daily routines long before residential accommodation becomes necessary. A person living alone in a remote settlement may have relatively modest care needs but face substantial practical barriers to receiving reliable assistance.

These circumstances expose a structural distinction between treating illness and supporting everyday life. Health services can diagnose conditions and provide treatment, while social services address practical assistance, personal care and social participation. Long-term care requires both systems to recognise how their responsibilities intersect.

Russia's demographic circumstances also vary substantially between federal subjects. Some regions have older population profiles, while others face different combinations of migration, workforce availability, household structure and settlement geography. National demographic trends therefore provide an important strategic direction but cannot, by themselves, determine local staffing requirements or the appropriate balance between home-based and residential support.

The planning challenge is to convert population-level evidence into an understanding of functional need. Two districts with similar numbers of older residents may require very different services because of variations in disability, housing conditions, informal caregiving, transport and access to primary health care.

A more integrated system must consequently assess not only how many people are ageing, but how people are ageing, what assistance they require and what combination of formal and informal support can realistically sustain their independence.

Understanding the institutional foundations of long-term care in Russia

Russia's care arrangements are shaped by a federal structure in which national legislation establishes important principles and entitlements while regional authorities hold substantial responsibilities for organising social services.

Federal Law No. 442-FZ, On the Fundamentals of Social Services for Citizens in the Russian Federation, provides a central legal foundation for social service provision. It establishes arrangements for recognising citizens as needing social services, preparing individual programmes, identifying providers and delivering assistance in different settings.

The law provides a framework for social services rather than a comprehensive, unified long-term care insurance scheme. This distinction matters because Russia's emerging Long-Term Care System operates alongside established social service and health care arrangements rather than replacing them with a single national insurance entitlement.

Health care is governed through a separate institutional framework, including Federal Law No. 323-FZ, On the Fundamentals of Health Protection of Citizens in the Russian Federation. Medical services are financed through arrangements that include compulsory medical insurance and public budgets, while social services depend substantially upon regional social protection systems and applicable funding rules.

The principal institutional responsibilities can be understood across several levels:

• Federal authorities: establish legislation, national policy priorities, methodological approaches and relevant financial support arrangements.
• Federal subjects: organise social service systems, determine regional implementation arrangements, oversee providers and allocate resources within their responsibilities.
• Social service organisations: assess and deliver practical assistance, home-based support, day services or residential provision according to their roles and applicable programmes.
• Health care organisations: provide medical assessment, treatment, rehabilitation and clinical services, with coordination required where health conditions affect everyday functioning.
• Families and informal caregivers: contribute substantial practical support, often bridging gaps between formal services and the realities of daily life.

The existence of these responsibilities does not automatically produce integration. Coordination requires mechanisms through which organisations share appropriate information, agree responsibilities and respond when a person's needs change.

It also requires clarity about accountability. A regional social protection authority may oversee social service provision without controlling hospital discharge arrangements. A medical organisation may identify functional deterioration without having direct authority to allocate social care assistance. An effective long-term care pathway must therefore connect decisions made under different administrative and financial arrangements.

What Russia's Long-Term Care System is intended to achieve

Russia began testing its Long-Term Care System in selected regions in 2018. Its development has been associated with national demographic and older-person support priorities, including work undertaken through the federal social protection system.

The SDU approach places greater emphasis on identifying people with substantial limitations in daily functioning, assessing their requirements and organising continuing assistance according to assessed need. Home-based support is particularly important because many older people prefer to remain in familiar surroundings when suitable care can be provided safely.

The model also recognises that care is not limited to occasional domestic assistance. Depending on an individual's circumstances and the services available locally, continuing support may involve personal care, help with mobility, assistance with daily routines, supervision and measures to maintain functional ability.

A significant element of the approach is the use of structured assessment, sometimes described through the Russian concept of determining an individual's level of need for care. This can provide a more consistent basis for deciding the intensity and type of assistance required.

However, assessment methods and operational arrangements need to be distinguished from guaranteed nationwide access. The SDU developed through regional pilots and subsequent expansion, and implementation conditions have varied. The existence of a federal framework does not establish that every older person in every locality receives an identical package of services.

The analytical question is therefore whether the programme can progressively establish a reliable continuum of support rather than remaining a set of administrative arrangements whose effectiveness depends heavily on local capacity.

Three features are particularly important: the quality of needs assessment, the availability of a workforce able to deliver the assessed assistance, and the ability of health and social service organisations to respond together when circumstances change.

From eligibility decisions to meaningful assessment of care needs

A coherent long-term care system begins with a reliable understanding of what a person can do independently, where assistance is required and what risks arise without support.

Traditional social service eligibility processes can identify a person's entitlement to assistance, but integrated long-term care requires a broader operational picture. A person may technically qualify for home-based services while still receiving insufficient support to manage significant difficulties with transferring, bathing or eating.

Assessment therefore needs to distinguish between the existence of a service and its practical adequacy.

Functional assessment can consider mobility, personal care, cognition, communication, household activities and the availability of informal assistance. It should also recognise environmental conditions. A person living on an upper floor without a lift may experience much greater restrictions than someone with similar health conditions in accessible accommodation.

The assessment should lead to a clear individual support arrangement, including the frequency and type of assistance, the responsibilities of participating organisations and the circumstances that should trigger reassessment.

For regional administrators, this creates a governance question: how consistently do different assessment teams interpret similar levels of need?

If one district allocates substantial home support while another provides only limited assistance for comparable circumstances, the difference may reflect genuine local conditions, inconsistent assessment or insufficient capacity. These explanations require different responses.

Organisations considering how to evaluate such governance arrangements can use the Governance Maturity Assessment to structure questions about accountability, decision-making and assurance. It is a general organisational framework rather than an instrument for determining eligibility under Russian law.

Operational scenario: coordinating support after hospital treatment in Tatarstan

Consider an illustrative case involving a 79-year-old woman living in Kazan, in the Republic of Tatarstan. Following hospital treatment for a hip fracture, she is medically stable but cannot safely manage bathing, meal preparation or stairs without assistance.

Her daughter works full-time and can provide evening support but cannot undertake daily personal care. Before the hospital admission, the woman had received occasional social assistance. Her circumstances now require a more substantial and coordinated response.

The hospital's medical team can identify rehabilitation needs and restrictions on mobility. The relevant social protection organisation must separately consider her eligibility and practical requirements for social services. If an SDU arrangement is available and applicable, structured assessment may inform the intensity of continuing care.

A workable plan would identify which activities require paid assistance, what rehabilitation or clinical follow-up is necessary and whether equipment or adaptations could reduce dependency. The daughter's contribution should be discussed realistically rather than assumed to be unlimited.

The principal operational risk is a gap between medical discharge and the start of appropriate home support. A hospital may consider discharge clinically appropriate while the social service organisation is still arranging staffing or confirming the available care package.

Clear communication between the organisations, the older woman and her daughter could reduce this risk. A named contact, agreed start date and reassessment following the initial recovery period would help ensure that the support responds to actual functional progress.

At regional level, repeated delays of this kind should prompt examination of referral processes, available care capacity and the relationship between rehabilitation and social support. The wider lesson is that integration must be visible at the point where one service's responsibility ends and another's begins.

Financing integration across different public systems

Financing is one of the most consequential issues in the development of Russia's long-term care arrangements. Social services and medical care operate under different funding mechanisms, creating a risk that an individual receives support according to administrative boundaries rather than their combined needs.

Russia's compulsory medical insurance system finances substantial areas of medical care within its defined arrangements. Social service provision, by contrast, is organised through regional social protection systems, with regional budgets, federal support measures and other applicable funding sources contributing according to the programme and service concerned.

Under Federal Law No. 442-FZ, social services may be provided free of charge or subject to payment depending on the type of service, the person's circumstances and applicable legal rules. The financial arrangements for services delivered through the SDU must be understood in relation to the relevant programme rules and regional implementation.

This is not equivalent to a single national long-term care insurance fund through which all assessed assistance is automatically reimbursed. The distinction affects planning, service continuity and financial accountability.

For example, an older person may require medical rehabilitation, daily personal assistance and transport to appointments. Each component may fall within a different organisational and financial responsibility. Without coordination, the person or family may be left to negotiate those boundaries independently.

Integration does not necessarily require every service to be financed from one budget. It does require the organisations involved to understand which support is available, who can authorise it and what happens when a necessary service falls outside an established funding pathway.

Regional authorities also need to distinguish between expenditure on the programme and the actual capacity it creates. A larger allocation may support additional workers, higher care intensity, better training or improved infrastructure. Those investments have different effects on outcomes and should be evaluated accordingly.

Long-term financial sustainability depends on understanding the relationship between assessed demand, unit costs, workforce capacity and the changing needs of people already receiving assistance.

A system that expands eligibility without developing sufficient delivery capacity risks creating expectations that local services cannot meet. Conversely, a system that limits support to existing capacity may underestimate the true scale of need.

Regional variation is a defining implementation challenge

Russia's federal structure and geographical scale make regional variation an unavoidable consideration in long-term care development.

Major urban centres generally offer a different operating environment from sparsely populated districts. In cities, services may benefit from larger workforce pools, more specialised organisations and closer proximity between hospitals, clinics and social service providers. In remote areas, travel distances, seasonal conditions and limited staffing can make even relatively straightforward assistance expensive and difficult to sustain.

Differences between federal subjects also arise from fiscal capacity, demographic characteristics, administrative experience and the maturity of existing social service networks.

National policy can establish shared objectives, but a uniform delivery model may not be practical across these circumstances. The stronger approach is to maintain consistent expectations about assessment, safety and outcomes while allowing regional service configurations to reflect local conditions.

This creates a distinction between equitable access and identical service organisation. An older person in a remote settlement should not necessarily receive care through the same operational model as someone living in central Moscow. They should, however, have their needs assessed fairly and have a credible pathway to appropriate assistance.

Regional comparisons can help identify whether differences in service intensity reflect population need or limitations in delivery capacity. Useful evidence includes the number of people assessed, levels of functional dependency, waiting periods, workforce availability, actual care hours delivered and reasons for interrupted support.

These measures should be interpreted alongside geography and household circumstances rather than used as simplistic performance rankings.

Operational scenario: maintaining care continuity in a remote Siberian district

In an illustrative rural district of Krasnoyarsk Krai, an 83-year-old man lives alone in a small settlement some distance from the nearest social service organisation. He has reduced mobility and requires assistance with personal care, food preparation and obtaining medication.

A relative living elsewhere in the region maintains telephone contact but cannot provide regular physical assistance. Winter travel conditions periodically restrict access to the settlement.

The regional social protection system may recognise the man's need for home support, but the operational question is how assistance can be delivered consistently. A worker travelling from a distant service centre may spend more time on transport than on direct care. Recruitment of a suitably trained local worker may be difficult, and reliance on one individual creates vulnerability during sickness or severe weather.

A sustainable response could combine scheduled professional visits, appropriate involvement from a local community support network and clear arrangements for obtaining urgent assistance. Any contribution from neighbours or volunteers would need to remain within safe boundaries and should not be treated as a substitute for personal care requiring trained staff.

The care plan would also need to identify who can respond if the usual worker is unavailable, how medicines are obtained and what circumstances require medical review or temporary alternative support.

Regional administrators could use information about missed visits, travel disruption and repeated emergency referrals to decide whether additional local workforce capacity or different delivery arrangements are justified.

This scenario demonstrates why integration in remote Russia must extend beyond organisational cooperation. It must incorporate transport, geography, weather resilience and the practical availability of people able to provide assistance.

Workforce development will determine the reliability of home-based care

The effectiveness of Russia's long-term care system ultimately depends on the people delivering assistance.

Social workers and care assistants may undertake different responsibilities depending on the organisation and service model. The expansion of more intensive personal care introduces requirements that differ from traditional forms of social assistance focused primarily on shopping, household tasks or administrative help.

Workers supporting people with significant functional limitations need practical competence in personal care, safe mobility assistance, communication, recognising deterioration and responding appropriately to emergencies. Supporting people with cognitive impairment or complex conditions may require additional supervision and specialist input.

Workforce planning must therefore address skill mix as well as headcount.

Training programmes can establish expected competencies, but practical supervision is needed to confirm that workers can apply those skills in people's homes. Home-based care presents particular challenges because much of the work takes place without continuous on-site oversight.

Care workers also need clear boundaries concerning clinical activities. A social care employee should not be expected to undertake a medical intervention merely because a person requires it and a health professional is unavailable. Where responsibilities overlap, organisations need appropriate authorisation, competence and professional oversight.

Retention is equally important. Repeated changes of worker can be particularly disruptive for people with dementia, communication difficulties or significant anxiety. Continuity supports trust, familiarity and earlier recognition of changes in wellbeing.

For regional planners, workforce sustainability involves several connected considerations: pay and employment conditions, training capacity, travel requirements, supervision, career development and the physical and emotional demands of care.

Organisations exploring comparable workforce pressures can use the Predictive Workforce Risk Module to examine how staffing trends may affect service continuity. Such modelling supports planning discussions but does not replace local workforce evidence or Russian employment requirements.

The development of a long-term care workforce also has a wider economic dimension. Reliable formal support can reduce the extent to which family members, particularly women, must withdraw from employment or reduce working hours to provide unpaid care.

That potential benefit should be recognised alongside the direct cost of providing services. A narrow calculation based only on care expenditure may overlook the effects on household income, employment participation and caregiver wellbeing.

Families are essential partners, but not an unlimited care resource

Family involvement remains central to long-term support in Russia. Relatives frequently provide assistance with personal care, shopping, medication routines, household management and emotional support.

Family caregiving can preserve familiar relationships and enable older people to remain within their communities. It can also provide continuity between formal service visits and help professionals understand an individual's preferences, routines and changing circumstances.

However, the existence of family support should not be interpreted as evidence that formal care is unnecessary.

A daughter who visits every evening may still be unable to assist her father safely with transfers during the working day. A spouse may provide extensive support while experiencing serious health difficulties of their own. A family member living nearby may be emotionally committed but lack the skills required to manage complex personal care.

Effective assessment must therefore consider the capacity, willingness and wellbeing of caregivers, rather than treating their availability as an automatic entitlement to unpaid labour.

This is particularly important when needs increase gradually. Families may adapt their routines repeatedly before recognising that the level of support has become unsustainable. By the time formal services are approached, the caregiver may already be exhausted.

An integrated care model should create opportunities for caregivers to raise concerns, receive practical guidance and understand how reassessment can be requested. It should also protect the older person's preferences and privacy, recognising that family interests and individual wishes are not always identical.

Operational scenario: responding to escalating care needs in Nizhny Novgorod

Consider an illustrative case involving an 81-year-old woman living with her husband in Nizhny Novgorod. She has increasing cognitive difficulties and requires frequent reminders, supervision with daily routines and assistance with personal care.

Her husband initially manages these responsibilities without formal support. Over time, disrupted sleep and the need for constant supervision begin to affect his own health. Their adult son lives in another city and visits when possible.

A social service assessment identifies the woman's increasing functional dependency, but the family's circumstances also require attention. The husband's presence does not necessarily mean he can safely provide all required assistance.

A coordinated response could involve reassessing the woman's support needs, considering the availability of more intensive home-based assistance and seeking relevant medical evaluation where cognitive or behavioural changes require clinical attention.

The husband would benefit from a clear explanation of available services, the limits of formal provision and how to obtain help if the situation becomes unsafe. Where appropriate services exist locally, day support or temporary alternative care could be considered, although availability should not be assumed.

The individual plan should recognise the woman's preferences, familiar routines and ability to participate in decisions. Her husband and son can contribute information, but their views should not automatically replace her own.

For the organisations involved, the case illustrates the importance of recognising caregiver strain as a factor affecting continuity and safety. Repeated urgent contacts or rapid deterioration in the husband's health should prompt a review of the overall support arrangement rather than being treated as unrelated incidents.

The central lesson is that supporting an older person and sustaining the family care network are connected responsibilities, even where they fall under different service arrangements.

Connecting health care, rehabilitation and continuing social support

Long-term care integration is most visible where health conditions and everyday support requirements overlap.

Russia's health care system includes primary care, hospital treatment, specialist services and rehabilitation arrangements. Social protection organisations provide different forms of assistance intended to support people in daily life. Although both systems may serve the same individual, their assessments, information systems and operational priorities are not necessarily aligned.

A person receiving rehabilitation following a stroke may make progress in mobility while continuing to require substantial assistance at home. Conversely, someone receiving social services may experience a deterioration that requires medical assessment rather than simply additional domestic help.

The practical challenge is establishing reliable communication between the relevant professionals and organisations without confusing their responsibilities.

Health care providers need to recognise when functional limitations require social support. Social service workers need clear routes for raising concerns about changing health conditions. Individuals and families need understandable information about which organisation to contact and what assistance can realistically be expected.

Information sharing should be proportionate, lawful and relevant to the person's needs. A social service organisation may require information about mobility restrictions or communication needs without requiring unrestricted access to an individual's medical history.

Integration should also involve review after significant events. Hospital admission, bereavement, a fall or a change in household circumstances may substantially alter the assistance required, even where the person's underlying diagnosis remains unchanged.

A mature system would treat these events as reasons to reconsider the support arrangement rather than requiring families to restart disconnected application processes whenever circumstances change.

Quality assurance must demonstrate more than service activity

As long-term care expands, regional authorities need dependable evidence that services are not only being delivered but are also meeting people's assessed needs.

Activity measures remain necessary. The number of people assessed, care workers employed and hours of assistance provided can demonstrate the scale of implementation. However, those figures do not establish whether the support is timely, appropriate or effective.

Quality assurance should connect the resources used with the experience and outcomes of people receiving care.

Relevant evidence may include:

• Whether assessed assistance begins within a reasonable period and continues reliably.
• Whether actual visits and care activities correspond to the individual's support arrangement.
• Whether changes in functional ability or household circumstances lead to timely reassessment.
• Whether people and caregivers understand how to raise concerns and obtain a response.
• Whether preventable disruptions, incidents and repeated emergency referrals generate service improvements.

These indicators require careful interpretation. A person with progressive disability may experience increasing dependency despite receiving high-quality care. Quality should not therefore be judged solely by whether functional ability improves.

Maintaining dignity, reducing avoidable distress, supporting informed choice and enabling safe continuity may represent meaningful outcomes even when underlying health conditions cannot be reversed.

Regional comparisons also need to account for differences in population need. A service supporting people with greater dependency may require more staff time and report more incidents without necessarily delivering poorer care.

The Quality Dashboard Builder offers a general framework for organising service performance, quality indicators and governance evidence. Applied thoughtfully, the underlying approach can help organisations examine whether reported activity corresponds to meaningful outcomes, although any indicators used in Russia would need to reflect its own programme rules and administrative context.

Digital coordination can support integration without replacing relationships

Digital systems could make an important contribution to the development of integrated long-term care in Russia, particularly where multiple organisations hold information about the same person's needs.

Structured assessment records, electronic support plans and service delivery information can help reduce duplication and improve visibility of changes in circumstances. Digital scheduling may also support the coordination of home visits across geographically dispersed areas.

However, the existence of electronic records does not mean that health and social service information can be exchanged automatically. Different organisations may operate separate systems, use different classifications and work under distinct information governance requirements.

Effective interoperability requires agreement about which information should be shared, for what purpose and with whose authority. It also requires attention to data accuracy, access controls and the consequences of incorrect or outdated information.

For older people, digital development should remain compatible with accessible communication. An online application process may be convenient for some families but create barriers for people without reliable internet access, suitable devices or confidence using digital services.

Russia's geographical scale makes remote communication and digital support potentially valuable, but technology should complement rather than replace the human assistance required for personal care, social contact and recognition of subtle changes in wellbeing.

Organisations considering comparable changes can use the Digital Transformation Readiness Assessment to examine governance, workforce preparation, information security and operational capability before introducing new systems.

The most important question is whether technology improves decisions and continuity. A sophisticated digital record offers limited value if staff cannot act on the information or if responsibility for responding to concerns remains unclear.

Operational scenario: using service information to prevent repeated disruption

In an illustrative district of Moscow Oblast, a social service organisation supports a group of older residents with varying levels of dependency. Several people require daily assistance, while others receive less frequent visits.

Over a period of weeks, staff absence and changing travel schedules lead to repeated late visits. The organisation continues to report that most planned care hours have been delivered, but several families raise concerns about unpredictable arrival times and missed opportunities for assistance with meals or personal care.

The service manager reviews the pattern and finds that overall activity figures conceal significant variation between individual households. People requiring time-sensitive support are experiencing greater disruption than those receiving more flexible domestic assistance.

A more useful operational response would distinguish between different levels of care dependency, identify visits where timing is particularly important and review whether staffing arrangements reflect those priorities.

Information from individual support plans, visit records and complaints could be examined together. The organisation might adjust worker allocation, establish clearer contingency arrangements and communicate more reliably with people receiving services.

Regional oversight should focus on whether the changes reduce repeated disruption, rather than merely confirming that a revised schedule has been produced.

If the same pattern persists across several organisations, the issue may require a wider examination of workforce supply, travel assumptions or the funding available for intensive home support.

This example illustrates how integration and quality improvement depend upon converting operational information into decisions that improve people's everyday experience.

Building a sustainable long-term care model over the next decade

Russia's long-term care development creates an opportunity to reconsider how public systems respond to functional dependency, family caregiving and the changing requirements of an ageing population.

The strongest direction is likely to involve progressive improvements in assessment, home-based care capacity, health-social coordination and the ability of regional authorities to understand unmet need.

Expansion should be accompanied by realistic financial planning. A larger population receiving support may increase immediate expenditure, while earlier assistance could help some people avoid preventable deterioration or unnecessary institutional care. Those potential benefits require evaluation rather than assumption.

Workforce development will be equally important. Greater reliance on home-based care requires trained staff, dependable supervision and service models that remain viable across different geographical conditions.

Regional flexibility should be preserved where it supports practical innovation, but differences in implementation should remain visible. National authorities need sufficient information to distinguish successful local adaptation from persistent gaps in access or quality.

Future development could also place greater emphasis on prevention and maintaining functional ability. Support with mobility, nutrition, social participation and appropriate rehabilitation may help some older people remain independent for longer. Nevertheless, prevention should not become a justification for withholding assistance from people whose needs are already substantial.

International experience offers useful principles without providing a single model that Russia could simply adopt. Countries with established long-term care insurance arrangements, tax-funded social services or integrated community care systems operate under different financial and institutional conditions.

The transferable lesson lies in the importance of connecting assessment, funding, workforce capacity and accountability around the person's actual needs. Whether those functions are organised through insurance funds, regional budgets or mixed arrangements is less important than whether they operate coherently.

Conclusion

Russia's development of a more integrated long-term care system represents a significant opportunity to improve the relationship between social services, health care and the everyday support required by an ageing population.

The foundations are not starting from nothing. Russia already has an established legal framework for social services, regional delivery structures and a developing Long-Term Care System intended to strengthen assessment and continuing assistance. The central challenge is converting these arrangements into dependable support across very different regional and household circumstances.

Success will depend on more than programme expansion. Older people need timely assessment, appropriate assistance and clear routes to reassessment when their circumstances change. Families need realistic recognition of their contribution and limitations. Care workers need the skills, supervision and working conditions necessary to deliver reliable support. Regional authorities need evidence that resources are translating into meaningful outcomes.

Health and social service organisations also need practical coordination arrangements that function beyond formal policy statements. Information sharing, discharge planning, rehabilitation and ongoing assistance should connect around the individual rather than leaving people to navigate separate administrative responsibilities.

The strongest long-term direction is a system that combines national expectations with regional adaptability, measures quality through lived experience as well as activity, and treats home-based support as a central component of social infrastructure.

Russia's experience demonstrates that integration is not achieved simply by establishing a programme or bringing services under a common policy objective. It is achieved when assessment, financing, workforce decisions and accountability operate together to provide consistent, dignified and sustainable support in everyday life.