Deinstitutionalisation in Spain: Moving Towards Community-Based and Person-Centred Care

Deinstitutionalisation is often described as a movement away from institutions, but the more important question is what people are moving towards. For an older person, disabled adult or somebody with long-term support needs, leaving a large residential setting has little value if the alternative is an inaccessible home, inadequate assistance, exhausted family care or social isolation. Community living becomes meaningful only when housing, support, relationships, healthcare and ordinary participation can work together.

Spain is increasingly confronting that distinction. Across the Spain Ageing, Long-Term Care & Community Support Knowledge Hub, the country’s long-term care direction is shaped by a national dependency framework delivered through highly decentralised regional systems. The 2024–2030 Estrategia estatal para un nuevo modelo de cuidados en la comunidad: un proceso de desinstitucionalización establishes an important strategic direction towards community-based, person-centred support, but it should not be interpreted as evidence that Spain has already completed such a transition.

The challenge is substantial because institutionalisation is not created by buildings alone. It can result from a shortage of home support, inaccessible housing, limited personal assistance, weak community infrastructure, workforce scarcity or service models that restrict choice even when they operate outside traditional institutions.

Spain’s stronger opportunity is therefore to treat deinstitutionalisation as a redesign of the care ecosystem. Success depends not on reducing residential capacity in isolation, but on expanding the practical conditions that allow people to live safely, autonomously and with meaningful control over their everyday lives.

Deinstitutionalisation is a system reform, not a property strategy

The term can create an overly physical image: people leave large buildings and move into smaller ones. Physical environment matters, but genuine deinstitutionalisation is broader.

An institutional model is characterised partly by how decisions are made. People may be required to fit predetermined routines, share living arrangements they did not choose, accept inflexible support schedules or have limited influence over who assists them and how. Those features can exist in a large facility, but some can also be reproduced in smaller community settings.

Conversely, residential care is not automatically incompatible with person-centred support. Some people require or prefer a residential setting, particularly where needs are very intensive, family support is unavailable or living alone would not reflect their wishes. The objective should not be to stigmatise residential care or treat every placement as policy failure.

The more useful distinction is between support organised around the institution and support organised around the person.

This aligns with wider principles of choice and control. A community-based system should increase the person’s influence over where they live, how their day is organised, what relationships they maintain and how support enables ordinary life.

Deinstitutionalisation therefore requires changes in service design, housing, funding, workforce deployment and governance, not simply changes in property portfolios.

Spain’s strategy sits within the wider evolution of the SAAD

The Sistema para la Autonomía y Atención a la Dependencia (SAAD), created by Law 39/2006, already contains several forms of support that can enable community living. These include prevention and promotion of personal autonomy, teleassistance, home help, day and night centres, personal assistance and economic benefits under the applicable conditions.

Residential care is also part of the SAAD catalogue. Deinstitutionalisation therefore does not sit outside the dependency system; it changes the balance and design of what that system is expected to achieve.

The national state can establish shared strategic direction and common criteria, while Autonomous Communities remain central to implementation. They organise and manage dependency services, regulate and inspect provision, maintain accreditation systems, administer assessment and PIAs and contribute substantially to financing. Local entities may also play significant roles according to regional arrangements.

This distribution of responsibility means reform will not occur identically across Spain. Existing residential infrastructure differs, as do home-care markets, workforce capacity, housing conditions and regional approaches to personal assistance and community support.

The central governance question is therefore whether a national strategic direction is being translated into sufficiently strong regional delivery systems.

Deinstitutionalisation becomes credible when the Programa Individual de Atención can identify a community option that actually exists, is adequately funded and can be sustained over time.

Community living depends on a real alternative being available

Closing or reducing institutional provision before credible alternatives exist can shift risk rather than resolve it.

A functioning community model may require several components around one person:

• accessible and secure housing;
• sufficient home support or personal assistance;
• primary and specialist healthcare;
• equipment, adaptations and assistive technology;
• transport and access to ordinary community life;
• respite and support for family carers where they remain involved; and
• contingency arrangements when needs, workforce or informal support change.

No single service necessarily supplies all of these elements.

That makes community living a coordination challenge. A person can hold a tenancy but still experience an institutional life if staffing arrangements dictate every routine. Someone can live with family but have little autonomy if there is no alternative to dependence on relatives. A person can receive home help but remain isolated if transport and community access are absent.

The principles of independence and community inclusion are therefore useful tests. The outcome is not merely the address at which care is delivered, but the life the person is able to live there.

Scenario: moving from a large residence requires more than a new apartment

María is 46 and has a physical disability. She has lived for several years in a large residential setting in a fictional Spanish region. She wants greater privacy and more control over her daily schedule, particularly around work, friendships and when she goes to bed.

A transition programme identifies an accessible apartment in the community. On paper, the move appears to fulfil the objective of deinstitutionalisation.

Yet several operational issues quickly become apparent. María needs assistance with transfers at predictable times but also wants flexibility when social plans change. Her current equipment needs to work safely in the new property. She requires accessible transport. Her healthcare providers need to know her new circumstances, and there must be a contingency plan if the support worker allocated to an evening shift is unavailable.

If those components are weak, María could gain a private front door while losing reliability.

The transition therefore begins with her goals rather than the vacancy. Housing, support, equipment and workforce arrangements are developed together, and the plan includes what happens during sickness, emergency or temporary increases in need. María participates directly in decisions about routines and support.

The case shows why person-centred planning for physical disability is central to deinstitutionalisation. The move is successful only if María gains meaningful control while maintaining the support required for safety and continuity.

Housing policy becomes care policy when community living is the objective

Housing is one of the least avoidable constraints in deinstitutionalisation.

Community-based support requires places where people can actually live. Older housing stock may contain stairs, narrow bathrooms, inaccessible entrances or layouts that make equipment and assistance difficult. Housing affordability and location also shape whether people can remain connected with families, transport and ordinary services.

For disabled people, an inaccessible home can create dependency that is partly environmental rather than intrinsic to impairment. For older people, relatively modest adaptations can sometimes make the difference between maintaining independence and requiring substantially more support.

This is why equipment and home adaptations should be understood as part of care-system capacity.

Regional and local planning therefore needs to connect housing supply with demographic and dependency projections. It is insufficient to expand home-care services if suitable homes are unavailable. Equally, building accessible housing without planning the support workforce creates another incomplete solution.

Deinstitutionalisation ultimately depends on aligning two systems that are often planned separately: where people live and how support reaches them.

Personal assistance can expand autonomy, but availability matters

Personal assistance has particular relevance to independent living because it can place greater control over support in the hands of the person. Law 39/2006 includes an economic benefit for personal assistance within the SAAD framework, although development and practical access vary across Autonomous Communities.

Its significance lies in the possibility of organising support around the person’s chosen life rather than around a predetermined service timetable.

That potential should not be romanticised. A legal category or financial benefit is not enough if the local supply of assistants is weak, funding does not cover sufficient support or people lack access to help with arranging and sustaining the model.

Regional capability therefore matters.

Organisations examining similar transitions can use the Positive Risk-Taking Planner as an adaptable framework for considering autonomy, risk, safeguards and review. It does not determine Spanish entitlement or legal decision-making, but it can help structure discussions where greater independence involves proportionate risk rather than its complete elimination.

Deinstitutionalisation should increase control without transferring all operational complexity onto the person.

Residential care also needs to change during deinstitutionalisation

A strategy focused only on people leaving residential care would overlook those who continue to need or choose it.

Spain’s 2022 common accreditation and quality criteria for SAAD centres and services strengthened the direction towards person-centred support, including greater attention to smaller-scale living arrangements and organisational models that move away from traditional institutional routines.

This is important because the future of residential care is part of deinstitutionalisation.

People living in a residential service should still retain privacy, relationships, personal routines, meaningful activity and connection with the surrounding community. Smaller living units may help, but architecture cannot guarantee culture. A beautifully redesigned building can still operate through rigid schedules and limited personal choice.

Quality assurance therefore needs to examine everyday life. Do residents decide when they get up? Can they maintain ordinary relationships? Are preferences reflected in meals and activities? Can they leave the service and participate in local life? Do workers know the person rather than only the care tasks?

This connects deinstitutionalisation with person-centred support for older people.

The strategic objective should be a continuum of support in which residential settings become less institutional while community alternatives become stronger, rather than a binary division between “good community” and “bad residential” care.

Scenario: redesigning residential care without simply rebadging it

A residential centre in a fictional Autonomous Community plans to reorganise part of a large building into smaller household-style living units. The physical redesign includes smaller shared spaces, more personalised bedrooms and decentralised dining.

The project could easily be declared successful once construction is complete.

Instead, the organisation examines whether operating practice has changed with the environment. Staff previously worked across large corridors and followed central routines. Meals were served at fixed times, activities were organised for large groups and shift responsibilities prioritised task completion.

Under the new model, workers are assigned more consistently to smaller groups of residents and are expected to understand personal histories, preferences and daily rhythms. Residents are supported to make more ordinary choices about meals, activities and time spent inside or outside their living area.

Management monitors not only incidents and staffing levels but continuity, participation, resident feedback and whether daily routines have genuinely become more individualised.

The Quality Dashboard Builder can help organisations structure this combination of workforce, quality and outcome evidence. It is not a Spanish accreditation tool, but it reinforces the need to distinguish environmental redesign from demonstrable improvement in people’s experience.

The scenario shows why deinstitutionalisation can occur within residential care as well as through movement out of it. Institutional culture is changed through practice, governance and relationships, not through floor plans alone.

Workforce redesign is one of the hardest parts of the transition

Community-based care often changes where labour is needed rather than reducing the need for labour.

A large residential setting concentrates staff in one location. Community support distributes workers across homes, neighbourhoods and municipalities. This can increase travel, scheduling complexity, lone-working considerations and the need for flexible supervision. Personal assistance may require different relationships and competencies from conventional service-led care.

Spain therefore cannot pursue deinstitutionalisation without substantial workforce planning.

Several workforce questions become critical:

• whether sufficient workers are available in the communities where people will live;
• whether pay and employment conditions support retention;
• whether workers have competencies for more autonomous, person-directed practice;
• whether community teams receive adequate supervision and support;
• whether rural geography makes particular models operationally difficult; and
• whether staff currently working in institutional settings can transition into new roles.

The final point matters for both workforce sustainability and reform legitimacy. Deinstitutionalisation should not assume that existing workers are an obsolete resource. Many have valuable knowledge and relationships that can support community models if training, roles and deployment evolve.

The Predictive Workforce Risk Module offers an adaptable way to examine whether recruitment, turnover and continuity risks threaten planned service changes. It is not specific to Spain, but the analytical principle is highly relevant: community reform needs workforce capacity before, not after, people move.

Family care should not become the invisible substitute for institutional capacity

Spain’s long-term care system has long depended significantly on family and informal support. Community reform creates a particular risk if reductions in formal institutional provision are offset by greater unpaid care within households.

That would change the location of care without necessarily increasing autonomy or sustainability.

Families can be invaluable partners. Many people want support from relatives and value the emotional continuity those relationships provide. But relatives differ in health, income, housing, employment, willingness and proximity. An older spouse may already be frail. An adult daughter may be balancing employment and children. A parent supporting a disabled adult may themselves be ageing.

Strong family partnership and carer support therefore requires the system to distinguish chosen family involvement from assumed substitution.

A community-care plan should answer three different questions: what does the person want relatives to do, what are relatives willing and able to do, and what formal support is necessary regardless of family involvement?

Where family care is central, respite, training and contingency become part of system resilience. The existing SAAD framework includes support for non-professional carers in relevant contexts, but the sustainability of community living cannot be reduced to a cash benefit alone.

Scenario: an older parent needs a future plan for her disabled son

Rosa is 70 and lives in Andalucía with her 39-year-old son Javier, who has significant physical support needs. Rosa has provided substantial care throughout his adult life. Javier wants to remain in his community and has no desire to move into a residential institution.

The current arrangement appears stable only because Rosa is doing extensive unpaid work.

Her own mobility is now declining. Without future planning, a hospital admission or sudden illness could create an immediate crisis in which Javier is offered whichever placement happens to be available.

A deinstitutionalisation-oriented response starts before that crisis. Javier is involved directly in planning how he wants to live if Rosa can no longer provide the same level of support. Personal assistance and other formal support options are explored within the applicable regional framework. Housing accessibility, equipment, community relationships and emergency arrangements are considered together.

Rosa remains important in Javier’s life without being treated as permanent infrastructure.

The wider principle of family partnership in physical disability support is central here. Respecting family contribution means supporting relationships while reducing dependence on a single unpaid carer where that dependence threatens future stability.

The most successful transition may be gradual. The objective is to build Javier’s chosen community life while Rosa is still able to participate in planning, rather than waiting until crisis removes meaningful choice.

Community living needs stronger contingency, not weaker governance

Institutions concentrate resources partly because they contain staff, equipment and management in one place. Distributed community models need different forms of resilience.

A person supported at home may depend on several separate systems: a care organisation, teleassistance, family, pharmacy, primary care, equipment maintenance and transport. Any one of these can fail temporarily.

Community support therefore requires explicit contingency planning.

What happens if the morning worker does not arrive? Who responds if an assistive device fails? What is the escalation route during severe weather? How does support change during a temporary health deterioration? Can another organisation provide emergency cover if a provider withdraws?

The answers will vary by service and territory, but the governance principle is consistent. Greater autonomy should not mean transferring unmanaged system risk to the person.

This is particularly important where support is highly individualised. A small-scale model can produce excellent continuity, but it may also have fewer immediate substitutes when one worker is absent.

Community care needs resilience designed around the person, not simply around the organisation delivering the largest component of support.

Technology can support community living without becoming digital institutionalisation

Teleassistance, sensors, digital care planning, remote communication and assistive technologies can all strengthen community support. They may reduce unnecessary travel, provide faster emergency response, support medication routines or give a person greater control over their environment.

But technology introduces an important ethical tension.

A system that replaces physical institutional surveillance with continuous digital surveillance has not necessarily advanced autonomy. Sensors, cameras or monitoring platforms can become intrusive if people do not understand or genuinely consent to their use. Relatives may also become informal monitoring centres, receiving alerts that transfer additional responsibility onto them.

The relevant standard is person-centred technology. Technology should solve a problem identified with the person, use the least intrusive approach capable of doing so and remain subject to review.

The same applies at system level. Digital tools can improve scheduling and information exchange, but a technology platform cannot create community support where workforce, housing or transport capacity is absent.

Organisations examining digital capability can use the Digital Transformation Readiness Assessment to consider strategy, workforce adoption, data governance and resilience together. It should be adapted to Spanish requirements rather than treated as a country-specific compliance mechanism.

The strongest technology is enabling rather than controlling: it gives people more freedom while preserving privacy and reliable human support.

Scenario: teleassistance extends independence but does not replace local response

Antonio, 87, lives alone in a rural municipality in Galicia. He wants to remain in the village where he has lived for decades. His daughter lives in another province, and formal support visits each day.

Advanced teleassistance and environmental sensors are considered as part of a wider plan. Antonio agrees to selected technology that can help detect a fall and allow rapid contact with the response service. His daughter values the reassurance.

The technology makes the community arrangement more robust, but it also exposes the limits of digital support. If Antonio falls and cannot get up, somebody must still reach him. If his mobility deteriorates, sensors will not provide personal care. If connectivity fails, the service needs another response route.

The plan therefore links technology with local physical response, primary care, formal support and contingency arrangements. Antonio’s preferences are reviewed periodically, including whether he remains comfortable with the level of monitoring.

The lesson is important for rural deinstitutionalisation. Technology can extend the reach of community support, but it cannot erase distance or workforce scarcity.

A credible community system combines digital and human infrastructure rather than using one to disguise weaknesses in the other.

Safeguarding must protect people without recreating unnecessary restriction

Deinstitutionalisation changes the environment in which safeguarding operates.

Living in ordinary housing can reduce some institutional risks and increase autonomy, but community settings create their own vulnerabilities. People may be more isolated, workers may operate alone, financial exploitation may be harder to detect and families can experience significant strain.

The response should not be to equate community living with unacceptable risk.

Safeguarding needs to remain person-centred and proportionate. The relevant question is how identified risks can be reduced while preserving the person’s choices and rights. This connects directly with capacity, consent and decision-making, particularly where cognitive impairment or communication difficulties are present.

Spain’s wider legal direction around disability and legal capacity reinforces the importance of supported decision-making rather than assuming incapacity simply because support needs are substantial.

Community reform should therefore improve the person’s ability to participate in decisions, access advocacy or support where required, and challenge arrangements that become unnecessarily restrictive.

Risk cannot be eliminated from ordinary life. The governance task is to understand it, share responsibility appropriately and avoid using safety as a reason to recreate institutional control in another setting.

Transitions need to be paced around the person rather than the programme

Large-scale reform creates pressure to demonstrate movement: numbers of beds reduced, people relocated or community places opened. Those metrics may show implementation activity, but they can distort practice if they become the primary objective.

A transition should begin with the person’s situation and preferences.

Some people may need gradual preparation for a move. Others may choose not to move. Families may require reassurance and involvement without being allowed to override the person automatically. Staff who know the person well can contribute valuable information about routines, communication and support needs.

Trial periods, phased support or gradual introduction to a new environment may help where appropriate. The important point is that transitions should not be rushed simply to satisfy programme milestones.

Once the move occurs, support needs active review. Early success can conceal emerging problems with loneliness, staffing, transport or health. The first weeks and months should therefore be treated as a period of learning rather than proof that the transition is complete.

The outcome is sustained community living, not the date on which somebody leaves a building.

Measuring deinstitutionalisation requires more than counting beds

Bed numbers are easy to count. Autonomy is harder.

That creates one of the most important evidence challenges for Spain’s strategy. A system may reduce large institutional capacity while expanding small settings that reproduce similar restrictions. Alternatively, residential capacity may remain necessary while practice within it becomes significantly more person-centred.

Meaningful outcome evidence should therefore examine several dimensions:

• whether people live where and with whom they choose, within realistic available options;
• whether support enables ordinary routines and community participation;
• whether family reliance is chosen and sustainable rather than assumed;
• whether people experience continuity and adequate support intensity;
• whether safeguarding and crisis events increase or reduce after transition;
• whether people retain or increase autonomy and decision-making control; and
• whether community placements remain stable over time.

This connects reform with quality data and performance metrics. Quantitative indicators are valuable, but they need qualitative evidence about lived experience and choice.

The strongest evaluation asks not only whether somebody moved, but whether their life improved in the dimensions that mattered to them.

Governance must connect national ambition with regional implementation

Spain’s decentralised system makes governance particularly important. National strategy can establish direction, but Autonomous Communities control many of the practical levers through which reform is delivered: service planning, accreditation, workforce, purchasing, assessment and regional investment.

That means national progress cannot be inferred solely from the existence of a strategy.

Decision-makers need evidence about how regional care patterns are changing, whether community capacity is expanding, whether residential practice is becoming less institutional, whether workforce supply matches new models and whether outcomes differ across territories.

Regional governments also need visibility below their own average. A community model may be developing well in a major city while remaining difficult in rural areas.

Organisations examining similar governance transitions can use the Governance Maturity Assessment as an adaptable way to test whether responsibilities, evidence and escalation pathways are clear. It does not replace Spanish institutional arrangements, but the principle is directly relevant: reform requires somebody to know whether policy is changing practice and what happens when it is not.

Deinstitutionalisation becomes accountable when progress can be demonstrated through people’s experience as well as programme activity.

Spain’s future direction depends on building community capacity before demand overwhelms it

Demographic ageing increases the urgency of the issue. If long-term care demand grows substantially while community infrastructure develops too slowly, the system may continue relying heavily on institutional solutions because they are the only immediately available capacity.

The answer is not to eliminate residential provision prematurely. It is to create enough community capacity that residential care becomes one appropriate option rather than the default response to insufficient alternatives.

That requires long-term planning across housing, workforce, home care, personal assistance, day support, teleassistance, transport and family support. It also requires financing models that recognise the real cost of dispersed community delivery.

Community support can appear less capital-intensive than residential care, but it is not cost-free. High-intensity assistance in ordinary housing can require substantial staffing. Rural routes create travel costs. Personalisation may require flexibility that does not fit highly standardised purchasing models.

The strategic advantage comes when investment produces outcomes that people value: autonomy, continuity, relationships and the ability to remain part of ordinary community life.

Spain’s 2024–2030 strategy therefore represents a direction of travel rather than an endpoint. Its success will depend on whether public investment, regional implementation and service redesign can build the alternatives required to make that direction credible.

What Spain’s approach offers international systems

Spain’s deinstitutionalisation programme is shaped by the SAAD, regional government responsibilities, its housing context and its own history of formal and family care. Other countries cannot simply reproduce its institutional arrangements.

The broader lessons are nevertheless highly relevant.

First, deinstitutionalisation should be defined through outcomes rather than buildings. Smaller settings and community addresses are useful only when they produce greater control and inclusion.

Second, reducing institutional capacity before expanding alternatives can transfer responsibility onto families or create fragile community arrangements.

Third, workforce planning is central. Distributed support requires people, skills, supervision and continuity in different places and often different patterns.

Fourth, residential care itself can become less institutional. Reform should improve the lives of people who remain in residential settings rather than treating them as outside the agenda.

Finally, governance needs to follow people after transition. A successful move should remain successful six months or several years later.

The transferable principle is therefore not “close institutions”. It is “build support around ordinary life”. Different systems can pursue that objective through different legal, funding and service structures.

Conclusion

Spain’s move towards community-based and person-centred care represents a significant change in how long-term support is understood. The 2024–2030 deinstitutionalisation strategy provides national direction, but the decisive work sits in implementation: building accessible housing, reliable home support, personal assistance, community infrastructure, workforce capacity and contingency around people who want greater control over where and how they live.

The reform should not be judged by the number of institutional beds removed in isolation. Nor should residential care be treated as inherently incompatible with dignity or personalisation. The stronger measure is whether people gain genuine choice, ordinary relationships, continuity, autonomy and support that remains sustainable when circumstances change.

That requires careful sequencing. Community alternatives need to exist before institutional capacity is withdrawn. Families should remain partners without becoming the unpaid substitute for missing services. Technology can extend independence but cannot replace human support or justify intrusive surveillance. Regional variation must be expected, while still remaining visible through common evidence and accountability.

Spain’s central strategic task is therefore to turn deinstitutionalisation from a destination into an operating model. Community living succeeds when housing, support, health, workforce and governance are organised around the person rather than around the convenience of institutions. If that principle guides implementation across the SAAD, the reform can become more than a relocation programme: it can change what long-term care is designed to enable.