Deinstitutionalisation in Lithuania: From Institutional Care to Community-Based Support

Moving a person from a large social-care institution into an ordinary neighbourhood can be a major change, but it is not in itself deinstitutionalisation. The decisive question is what happens after the front door closes. Can the person choose when to get up, where to go, whom to see and how to spend their money? Can they access healthcare, employment and community life? Do staff support decisions rather than routinely make them? Is there somewhere to turn when circumstances deteriorate?

Lithuania has spent more than a decade reorganising institutional social care, particularly for adults with intellectual and psychosocial disabilities. The national direction has been towards smaller community-based living arrangements, supported housing, personal assistance, case management, social workshops, supported employment and other services intended to reduce reliance on large segregated institutions.

This fifteenth article in the Lithuania Ageing, Long-Term Care & Community Support Knowledge Hub examines that transition as a system reform rather than a building programme. The central challenge is not simply to reduce institutional places. It is to create enough housing, workforce, rights-based practice, community infrastructure and crisis support for people to live ordinary lives outside institutions without transferring institutional routines into smaller settings.

That distinction matters internationally. Deinstitutionalisation can be presented as a numerical achievement: fewer people in large facilities, more people in community accommodation. The stronger measure is qualitative. Has control moved from the institution to the person?

Why Lithuania began reorganising institutional social care

Lithuania inherited a model in which many adults with intellectual and psychosocial disabilities lived in large social-care institutions, often geographically and socially separated from ordinary community life. Institutions could provide accommodation, personal care and supervision, but the model inherently concentrated control over daily life within organisations.

People might share routines, mealtimes, staffing arrangements and living environments determined largely by the institution. Opportunities for employment, relationships, ordinary neighbourhood participation and individual choice could be constrained by the setting itself rather than by the person’s impairment.

Lithuania’s reform direction has increasingly reflected a rights-based understanding of disability: people should be able to receive support in the community and participate in society rather than being segregated simply because they require assistance.

The Ministry of Social Security and Labour coordinates the wider institutional-care reorganisation, working with municipalities, disability bodies, social-service organisations, non-governmental organisations and other public institutions.

The objectives have included developing individual community services, reducing reliance on large social-care homes and changing societal expectations about where and how people with disabilities should live.

This connects directly with wider service models and care pathways for people with learning disabilities. A pathway built around institutional placement asks where someone can be accommodated. A community-based pathway asks what combination of housing and support will enable that person to live well.

The reform has moved from pilots towards wider community infrastructure

European Union funding has been an important accelerator of Lithuania’s transition. Earlier projects tested new community-based models and demonstrated how people could move from social-care institutions into homes and apartments within ordinary neighbourhoods.

One significant programme introduced community-based services across 36 municipalities, helping people with intellectual and psychosocial disabilities move from institutional care towards community living. The experience helped establish approaches that could subsequently be expanded.

The reform has since broadened. Lithuania has developed group living homes, protected housing, social workshops, supported employment, personal assistance and decision-making support, while case-management arrangements have been expanded across almost all municipalities.

By late 2024, the Ministry of Social Security and Labour described a case-management model being introduced in 59 municipalities. The intention is to identify the needs of disabled people living in the community early, coordinate services across sectors and help municipalities plan community alternatives before institutional care becomes the default response.

This is strategically important.

Deinstitutionalisation is more sustainable when the system prevents unnecessary institutional admission as well as supporting people to leave existing institutions. Otherwise, one part of the system moves people out while another continues directing new people in.

Group living homes are one part of the transition, not the destination

Group living homes have become one of the most visible components of Lithuania’s reform. They allow small numbers of people with intellectual or psychosocial disabilities to live in ordinary residential environments with support from social workers and individual-care workers.

Compared with large institutions, the scale can make ordinary domestic life easier. Residents can shop locally, prepare meals, use public transport, participate in activities and develop everyday living skills with staff support.

That represents a significant structural difference.

Yet size alone does not determine whether a setting is genuinely community-based.

A ten-person home can still reproduce institutional culture if everyone follows the same timetable, staff control money, community participation happens only in organised groups and residents have little influence over who they live with.

Conversely, a well-designed group living home can provide a stable stepping stone or long-term home where people have meaningful control and support is individualised.

The distinction connects with wider supported-living service models. The key analytical question is not what the building is called, but whether housing, support and decision-making are organised around the individual.

Scenario: leaving an institution changes the address before it changes the life

A 45-year-old man with an intellectual disability has lived in a large social-care institution for many years. He moves with several other residents into a newly established group living home in a Lithuanian municipality.

Physically, the change is substantial. He now lives in an ordinary neighbourhood, has his own bedroom and can walk to local shops.

During the first months, however, staff continue routines familiar from institutional care. Residents eat at fixed times, shopping is completed collectively and everyone attends the same organised daytime activity because scheduling separate support is difficult.

The building has changed, but the operating culture has not fully changed with it.

A review begins with the man’s own preferences. Staff discover that he wants to learn to cook one evening meal himself, visit a nearby sports club and spend more time with a brother who lives locally.

Support is reorganised around these goals. Staff assist him to plan shopping rather than completing it for the whole house. His brother becomes involved with his agreement. Some staffing time is made flexible so residents do not always have to leave the home together.

The change creates more work initially because individualised support is less predictable than a shared routine. Over time, however, the man becomes more independent in activities previously completed by staff.

The scenario demonstrates why deinstitutionalisation is a practice transformation. Community living requires services to tolerate individual variation rather than organising people primarily around workforce convenience.

Protected housing creates a different relationship between housing and support

Lithuania has also developed protected housing, particularly for adults with psychosocial disabilities who can live with lower levels of direct assistance.

Under this model, a small number of people can live in a rented home or apartment while receiving regular support from a case manager or social worker. The intention is to strengthen independent-living skills and minimise professional intrusion rather than creating a continuously staffed care environment.

The model highlights an important principle: support intensity should not automatically determine housing status.

People can require advice, coordination or practical assistance while still having a home that feels and functions like an ordinary home.

This separation between housing and care is central to genuine independence. If a person risks losing their home whenever their provider changes, or if their tenancy depends entirely on compliance with a particular support regime, housing can become another form of service control.

The principles of housing and environmental design in supported living therefore extend beyond physical accessibility. Security, privacy, location and control over the living environment all shape independence.

Case management is intended to prevent people falling between systems

Community living creates more interfaces than institutional care.

Inside a large institution, accommodation, meals, support and many activities may be provided within one organisation. In the community, a person may separately use municipal social services, healthcare, housing, employment support, transport and community organisations.

That diversity is potentially empowering because the person uses ordinary systems rather than living inside one all-purpose institution.

It also creates coordination risk.

Case management is therefore a significant part of Lithuania’s reform. Its purpose is to identify individual needs, bring relevant services together and help municipalities see where community infrastructure is missing.

The strongest case management does not simply become another administrative layer. It should reduce the number of boundaries the person has to manage.

For example, repeated difficulty finding employment support, accessible housing or crisis services should not be treated as an individual navigation failure each time. Aggregated case-management evidence should inform municipal planning.

Organisations examining comparable reforms can use the Governance Maturity Assessment to test how responsibility, escalation and learning are structured. It is not a Lithuanian regulatory instrument; the transferable governance question is whether recurring barriers move upwards from individual cases into system decisions.

Deinstitutionalisation requires services for people already living with families

One of the most important tests of reform is what happens to people who have never entered an institution.

Many adults with significant disabilities live with parents or other relatives. Family support can sustain community life for years, but ageing carers, changes in health or family circumstances can make that arrangement increasingly fragile.

If the only high-intensity alternative available when family care breaks down is institutional placement, the system continues reproducing institutional demand.

Community-service expansion therefore needs to reach families early.

Personal assistance, community rehabilitation, respite, supported employment, day opportunities, protected housing and other forms of support can all reduce the likelihood that a future crisis becomes an institutional admission.

This changes the meaning of deinstitutionalisation from a finite project involving existing residents to a permanent service-design principle.

Scenario: an ageing parent exposes the next institutional-care risk

A 68-year-old mother in a smaller Lithuanian municipality lives with her 37-year-old son, who has an intellectual disability. She has supported him throughout adulthood. He attends community activities periodically but has never lived away from the family home.

The mother develops a significant health problem and is admitted to hospital.

The immediate concern is where her son can stay. If no alternative community support has been developed, an emergency institutional placement may appear to be the fastest option.

A preventative case-management approach would have identified the household’s vulnerability earlier. The son’s skills, preferences and support needs could have been assessed while his mother was still able to participate. Supported housing or another community option could have been explored gradually rather than during crisis.

Following the mother’s illness, the municipality coordinates a temporary support arrangement while a longer-term housing option is developed. The son is involved in choosing the location and preparing for the move rather than being transferred to whichever vacancy exists first.

The scenario illustrates a fundamental point: successful deinstitutionalisation depends as much on preventing future institutionalisation as on relocating people already living in social-care homes.

Community living needs meaningful occupation as well as housing

A person can live in an ordinary apartment and still spend most of the day isolated from ordinary society.

Lithuania’s development of social workshops and supported-employment services reflects recognition that community inclusion involves occupation, relationships and economic participation as well as accommodation.

Social workshops aim to develop work and social skills for people with intellectual or psychosocial disabilities, with an emphasis on increasing independence and, where appropriate, progression towards the open labour market.

The model is valuable where it creates meaningful activity and development rather than a permanent segregated destination.

Employment support similarly matters because moving into the community can increase living costs and personal responsibility. Income and participation become central to independence.

The wider principles of housing, employment and social inclusion are particularly relevant for people with psychosocial disabilities.

The stronger measure of reform is therefore not simply where a person sleeps. It is whether they are increasingly present in ordinary community life.

Supported decision-making challenges institutional habits of control

Institutional systems often develop paternalistic decision-making because organisations are responsible for large numbers of people and risk is managed collectively.

Community living requires a different approach.

Lithuania has expanded assistance with decision-making as part of disability reform. The underlying principle is that people who require support to understand choices should receive that support rather than automatically having decisions made for them.

This is especially important for people with intellectual or psychosocial disabilities, whose preferences may historically have been overridden because professionals or relatives believed they knew what was safest.

Supported decision-making can involve accessible information, trusted supporters, more time, different communication approaches and assistance understanding consequences.

It does not mean that every decision will be straightforward or that serious safeguarding concerns disappear.

The key distinction is whether support starts from the person’s will and preferences rather than from organisational convenience.

The principles of co-production, choice and control therefore sit at the core of deinstitutionalisation.

Risk changes when people gain ordinary freedom

Large institutions control many everyday risks by controlling the environment itself. Doors, staffing, routines, visitors, transport and activities can all be managed centrally.

Community living removes some of that control by design.

People may travel independently, form relationships, manage money, use public transport, cook, work and decide how to spend time. These activities create ordinary life and ordinary risk simultaneously.

A rights-based system cannot respond by recreating institutional restrictions in the community.

Instead, support should identify the particular risk, understand the potential benefit and introduce proportionate safeguards where possible.

The wider principles of positive risk-taking are particularly important during transition because staff may be anxious about responsibility when a person begins doing things previously prohibited or controlled.

Organisations facing comparable decisions can use the Positive Risk-Taking Planner to structure benefits, risks, safeguards and review. It does not determine Lithuanian legal requirements, but it helps illustrate the essential distinction between managing risk and eliminating autonomy.

Scenario: community inclusion creates a risk the institution previously removed

A woman with a mild intellectual disability moves from institutional care into protected housing. She begins travelling independently by bus and develops friendships through a local activity group.

Staff become concerned when she starts meeting a new friend alone in the city. In the institution, unsupervised meetings would not have occurred.

The easiest response would be to require staff accompaniment. That would reduce one risk but also remove privacy and undermine the independence the move was intended to create.

Instead, staff discuss the relationship with her, explore what she understands about personal and financial safety and agree how she can seek support if she feels uncomfortable. Her right to make personal choices remains central.

The situation is reviewed if concerns emerge, but restriction is not imposed simply because uncertainty exists.

The scenario demonstrates why deinstitutionalisation requires a different risk culture. Community life cannot be authentic if every freedom is conditional on professional supervision.

Workforce transformation is harder than workforce relocation

When services move from institutions into community settings, staff may transfer with them. That protects experience and employment continuity, but it does not automatically change practice.

Institutional workers may be accustomed to collective routines, centralised decision-making and clear organisational control. Community support requires greater flexibility and often more independent judgement.

A worker in a group living home may need to support several residents pursuing different plans simultaneously. A protected-housing worker may spend relatively little time physically present and must judge when intervention is necessary rather than supervising continuously.

Training therefore needs to go beyond new procedures.

Staff need competence in person-centred planning, supported decision-making, positive risk-taking, safeguarding, community inclusion and working with families without allowing family preference automatically to override the person.

Supervision is particularly important because workers need a place to discuss uncertainty rather than responding to uncertainty through restriction.

Workforce planning also needs to recognise that community models can require different deployment patterns. Smaller dispersed services may increase travel and reduce some economies of scale that existed in large institutions.

Housing supply can become the hidden constraint on reform

Deinstitutionalisation cannot progress faster than suitable community housing unless people are moved into temporary or poorly matched arrangements.

Lithuania has invested in group living homes and protected housing, but future expansion still depends on location, affordability and the availability of ordinary housing.

Housing needs to be considered alongside transport, healthcare, employment and community amenities. A technically suitable apartment can still create isolation if it is located far from ordinary services.

Concentrating multiple disability services within one neighbourhood can also inadvertently create a new institutional cluster even where individual buildings are small.

The stronger opportunity lies in dispersal and integration.

People should live in neighbourhoods because those places suit their lives, not simply because land was available for a funded project.

This is why housing strategy and social-care strategy need to interact much earlier than the point at which someone is ready to leave an institution.

EU investment has accelerated change, but recurrent funding determines sustainability

European Union structural funding has been central to building Lithuania’s alternative infrastructure. Capital investment can create homes, renovate properties, develop service models and finance initial programmes.

However, buildings do not operate themselves.

Community services require continuing expenditure on staff, supervision, transport, maintenance, utilities, case management and specialist support.

This creates a familiar reform risk: transformation funding pays for the transition while long-term sustainability depends on national and municipal budgets after project funding ends.

Financial planning therefore needs to distinguish capital transformation from recurrent operating cost.

A community model should not be judged solely by whether it is cheaper than an institution. It should be judged by whether it is affordable, sustainable and capable of delivering better rights and outcomes.

Some community services may cost more for particular individuals because support is highly personalised. That does not automatically make them inefficient.

Equally, rights-based language should not prevent scrutiny of whether resources are producing meaningful independence.

Crisis support is a critical test of whether community living can endure

Community services are most vulnerable when a person’s needs change suddenly.

A person with a psychosocial disability may experience an acute mental-health crisis. Someone with an intellectual disability may develop severe distress following bereavement, illness or a breakdown in routine. A family placement may collapse. A community provider may struggle to maintain support.

If the only robust response to complexity is admission to hospital or return to institutional social care, community support remains fragile.

This is why deinstitutionalisation needs crisis capacity as well as ordinary day-to-day services.

The wider principles of community mental-health and integrated support are therefore relevant to the reform.

Community services need access to specialist advice, temporary additional staffing, healthcare assessment and clear escalation routes. Municipal social services and healthcare cannot treat deterioration as belonging entirely to the other system.

The objective is not to prevent every hospital admission. Acute inpatient treatment may sometimes be appropriate. The important distinction is between clinically necessary admission and institutional placement caused primarily by a gap in community capacity.

Scenario: a crisis tests whether community living is genuinely sustainable

A 31-year-old man with a psychosocial disability lives in supported community accommodation after several years in institutional care. For more than a year he manages well with regular support and attends a social workshop.

Following the death of a close relative, his mental health deteriorates. He stops attending activities, sleeps poorly and becomes increasingly suspicious of support workers.

The provider begins to question whether the placement can continue.

If the service model has no capacity to intensify temporarily, return to institutional care may start to look inevitable.

A stronger response brings health and social support together. Mental-health assessment is arranged, staffing is increased temporarily and the man is offered more control over which workers support him. His existing home is protected while treatment and additional assistance are provided.

If a short hospital admission becomes necessary, it is treated as healthcare rather than as automatic evidence that community living has failed.

After stabilisation, support reduces gradually.

The critical outcome is not that crisis was avoided. It is that crisis did not permanently remove the person’s home and community life.

Quality assurance must distinguish a small home from an institutional culture

Traditional quality monitoring can identify important matters such as staffing, documentation, incidents, complaints and physical safety.

Deinstitutionalisation requires additional questions.

Do residents control everyday routines? Can they choose food and activities? Do they have privacy? Are they supported to maintain personal relationships? Do staff enter bedrooms appropriately? Can people make ordinary mistakes without every event becoming a restrictive policy response?

A technically compliant service can still be highly institutional in culture.

Quality monitoring therefore needs evidence of ordinary life as well as organisational control.

Relevant indicators can include:

• choice over routines, relationships and personal spending;
• individual rather than group-based community participation;
• employment, education and meaningful occupation;
• use of restrictive practices and the reasons for them;
• continuity of staff and access to specialist support;
• resident and family feedback, including accessible feedback methods; and
• movement towards greater independence where this reflects the person’s goals.

The Quality Dashboard Builder can help organisations exploring comparable reforms bring quality, workforce and outcome evidence together. It does not reproduce Lithuanian social-care regulation; its relevance lies in ensuring that operational measures are connected with the outcomes the reform is intended to achieve.

Safeguarding remains essential in community settings

Institutional care has historically been associated with risks arising from segregation, power imbalance and closed cultures. Community living can reduce some of these structural risks, but it does not remove vulnerability.

Abuse can occur in any setting, including private homes, families, supported accommodation, workplaces and community services.

Some risks can become less visible when people live in dispersed settings because there is less routine organisational observation.

The relevant principles of safeguarding, restrictive practice and human rights therefore remain central.

People need accessible information about rights and complaints. Staff need clear escalation procedures. Providers and municipalities need to recognise patterns of exploitation, neglect or coercion without responding by unnecessarily restricting everyone’s freedom.

Independent relationships outside the service can also strengthen safeguarding. A person who knows neighbours, colleagues, relatives and community organisations has a wider social network capable of noticing change.

Community inclusion is therefore not separate from protection. Social connection can itself be protective.

Technology can support independence but should not recreate institutional surveillance

Digital technology can make community living easier. Communication tools, environmental controls, medication prompts, remote contact and assistive technologies can reduce dependence on staff and support people living with lower levels of direct supervision.

The same technology can also become intrusive.

A provider may be tempted to use extensive sensor monitoring because staff are not continuously present. That can reproduce institutional surveillance digitally even where the physical institution has disappeared.

The person’s privacy, understanding and preferences therefore matter.

Technology should answer a specific support need and have a clear response model. Collecting more information is not inherently safer if nobody knows how it should influence care.

Digital tools are strongest when they increase personal control rather than organisational observation.

Municipal variation will influence the pace and quality of reform

Lithuania’s municipalities differ considerably in population, workforce, provider capacity and housing markets. That inevitably affects the development of community alternatives.

A large urban municipality can support a wider range of providers and employment opportunities. A smaller municipality may struggle to maintain specialist services while still offering the advantages of close community networks.

Different delivery models are therefore reasonable.

What matters is whether variation creates materially different rights.

A person should not face institutional placement primarily because they happen to live in a municipality where supported housing or crisis support has not developed sufficiently.

National oversight consequently needs to examine geographic access, waiting, institutional admissions and community-service capacity alongside local autonomy.

Where individual municipalities cannot sustain specialist infrastructure alone, intermunicipal cooperation may offer part of the answer.

Scenario modelling can test whether institutional reduction is matched by community capacity

Suppose a Lithuanian region plans to reduce reliance on several large institutional facilities over five years.

The headline target is straightforward: fewer institutional places.

The operational model underneath it is more complex. Leaders need to know how many people may need group living homes, protected housing, personal assistance or intensive community support. They need forecasts for workforce, housing, transport and crisis capacity. They must also consider people currently living with families who may require services during the same period.

If institutional capacity falls faster than community capacity rises, waiting and crisis placement may increase.

If community housing is built faster than skilled workforce can be recruited, new services may operate below their intended model.

The Digital Twin Scenario Modeller can help organisations test comparable relationships between demand, workforce and service capacity. It is not designed specifically for Lithuania, but the planning principle is directly relevant: deinstitutionalisation should be modelled as a transfer of system capacity, not merely a reduction in beds.

The next stage is preventing institutional culture from surviving institutional closure

Lithuania has already demonstrated that people can move from large social-care homes into ordinary neighbourhoods and that alternative community services can be developed at scale.

The next stage is less visible but more demanding.

It involves strengthening personalised practice, ensuring housing feels like home, increasing employment and ordinary community participation, supporting decision-making and improving crisis response. It also means listening carefully to people who have moved through the reform.

The question should be not only whether they prefer the new building, but whether they experience greater control.

This is where the principles of service-user feedback and co-production become essential. People with lived experience can identify forms of institutional practice that are invisible in formal reporting.

If everyone in a group home still follows one schedule, if residents cannot choose who enters their room or if staff routinely decide how money is spent, those details matter as much as the size of the building.

What other countries can learn from Lithuania’s deinstitutionalisation

Lithuania’s reform is shaped by its post-Soviet institutional legacy, municipal social-service structure, European Union membership and use of structural funding. Countries with different housing systems, disability legislation or service infrastructures cannot directly replicate its programme.

Several principles are more widely transferable.

First, deinstitutionalisation needs alternatives before closures. Housing, workforce, crisis support and community services are the infrastructure of reform.

Second, prevention matters. Supporting adults who live with ageing relatives can reduce future institutional demand.

Third, small-scale accommodation is not automatically independent living. Organisational culture, rights and daily choice determine whether institutional practices survive.

Fourth, investment needs a recurrent-finance plan. Capital programmes can build community settings, but sustainable support depends on long-term operating resources.

Finally, the success measure should move beyond placement. The deeper outcomes concern autonomy, relationships, employment, participation and whether people genuinely control more of their own lives.

The transferable lesson lies less in Lithuania’s particular service labels and more in understanding deinstitutionalisation as a redistribution of power as well as resources.

Conclusion

Lithuania’s move away from large institutional social-care settings represents one of the most significant changes in the country’s disability-support model. Group living homes, protected housing, personal assistance, social workshops, supported employment, decision-making support and expanding case management have created alternatives that would once have been far less available to people with intellectual and psychosocial disabilities.

The strategic task now is to deepen the reform. Reducing institutional capacity is only sustainable when municipalities can provide credible community alternatives, families receive support before crisis, staff are equipped for rights-based practice and people retain their homes when health or behaviour changes. European investment has accelerated infrastructure development, but recurrent funding, workforce capacity and housing supply will determine whether that infrastructure endures.

Most importantly, Lithuania needs to judge the reform through everyday life rather than building type. A small home can remain institutional if routines, risk and decisions are still controlled collectively. Community-based support becomes meaningful when people gain privacy, relationships, occupation, personal choice and the ability to take ordinary risks with proportionate assistance.

The strongest future direction is therefore not merely from large institutions to smaller services. It is from institutional dependence towards citizenship: a system in which people with disabilities live in ordinary communities, use ordinary services where possible and receive the individual support required to exercise rights that do not end at the boundary of a care setting.