Health and Social Care Integration in France: Coordinating Hospitals, Primary Care, Home Support and Long-Term Care

An older person with frailty, diabetes and early cognitive decline may interact with a médecin traitant, community nurses, pharmacy, hospital specialists, a service autonomie à domicile, the département, an EHPAD respite service and family carers within a relatively short period. Each part of that network can be competent in its own right. The harder question is whether the person experiences it as one coherent pathway.

That question sits at the centre of France’s wider Ageing, Long-Term Care & Community Support system. France does not operate a single organisational structure combining health care and long-term care. Instead, integration is pursued through coordination between health services, social and médico-social organisations, départements, agences régionales de santé, primary care professionals and increasingly territorial coordination mechanisms.

This architecture reflects a practical reality. The needs of an older person rarely remain within one administrative category. A deterioration in mobility may require clinical assessment, additional home support, medication review and housing adaptation. A hospital admission may expose previously hidden carer strain. Cognitive decline may turn an apparently straightforward home-care arrangement into a complex question involving safety, primary care, family support and longer-term planning.

France has therefore invested in organisations intended to bridge these boundaries, including communautés professionnelles territoriales de santé, dispositifs d’appui à la coordination and the reformed services autonomie à domicile. The central challenge is no longer recognising the need for integration. It is ensuring that these structures create simpler pathways rather than another layer that people and professionals must navigate.

France Integrates Care Through Networks Rather Than a Single Organisation

France’s health and long-term care responsibilities remain institutionally distinct.

Health care is predominantly organised through the health system and Assurance Maladie, with the agences régionales de santé playing a major role in regional health planning and organisation. Primary care is delivered through independent and salaried professionals, including médecins généralistes, nurses, pharmacists, physiotherapists, centres de santé and multidisciplinary practices.

Long-term care and autonomy support sit partly within the separate branche Autonomie of Social Security. Départements retain major responsibilities for APA and territorial social support, while CNSA supports national financing, policy and information infrastructure.

EHPADs and other établissements et services sociaux et médico-sociaux sit between these worlds because residents often have substantial health needs as well as needs associated with loss of autonomy.

No single organisation therefore controls the whole older person’s pathway.

Integration depends on relationships between organisations that retain different funding, governance and professional cultures.

This makes multi-agency working central to France’s model. The operational question is not whether multiple actors exist, but whether their responsibilities connect at the points where a person’s needs change.

The Médecin Traitant Remains a Core Clinical Coordinator

France’s médecin traitant occupies a central position within the coordinated care pathway.

For an older person with several chronic conditions, the treating doctor may hold the longest continuous clinical relationship and is often the professional best placed to understand how specialist recommendations, medicines and changing functional needs interact.

But the médecin traitant cannot integrate the whole pathway alone.

Long-term care increasingly involves social needs that sit outside conventional clinical practice. A GP may identify that a patient is falling more frequently, losing weight or becoming confused, yet another organisation may need to assess APA, organise home support, address housing conditions or support a family carer.

The effectiveness of the physician’s coordinating role therefore depends on access to other professionals and on the ability to refer, exchange information and obtain timely feedback.

This is particularly important where the person has several specialists. Without coordination, a cardiology recommendation, diabetes treatment, pain prescription and geriatric assessment can each be individually reasonable while collectively creating medication burden or conflicting priorities.

France’s move towards stronger territorial primary-care organisation is partly intended to address this problem.

CPTS Create a Territorial Layer Around Primary Care

Communautés professionnelles territoriales de santé, or CPTS, bring health professionals together around the needs of a defined population rather than around a single building or employer.

Their missions extend beyond individual clinical consultations. They include facilitating access to a médecin traitant, organising responses to unscheduled care, strengthening prevention and developing coordinated pathways between professionals and services.

For older people, this pathway function is particularly important.

A CPTS can create links between general practice, pharmacies, community nursing, physiotherapy, hospitals and médico-social organisations. It can help develop agreed routes for common problems such as falls, frailty, medication risk or deterioration after discharge.

The value is territorial rather than organisational.

A community nurse, GP and pharmacist may remain independent professionals but work within a shared pathway designed for the local population.

This approach can reduce fragmentation where coordination problems arise repeatedly across the same territory.

It also creates a way to move from informal professional goodwill towards agreed operational processes.

However, CPTS coverage does not automatically mean that every older person has an integrated pathway. Effectiveness depends on professional participation, local maturity and the quality of relationships with hospitals and the social and médico-social sectors.

Operational scenario: Repeated falls become a territorial pathway problem

An 82-year-old woman living alone attends an emergency department twice in three months following falls. Neither event produces a major injury, and she returns home.

Looked at individually, each episode appears successfully resolved.

Her médecin traitant, however, can see a wider pattern. She has recently started a new antihypertensive medicine, is becoming less active and has begun relying more heavily on her daughter for shopping.

Within a territory where the CPTS has established a falls pathway, the GP can trigger coordinated follow-up involving community nursing, physiotherapy, pharmacy review and, where appropriate, connection with département-level prevention or autonomy support.

The value lies not in creating one more referral. It lies in connecting clinical and functional evidence.

The hospital episode becomes visible to primary care. Medication risk is reviewed. Mobility is assessed. If the person’s difficulties extend beyond health care, the pathway can connect with social or autonomy services rather than waiting for another emergency event.

This reflects the wider principle of frailty, falls and medication safety: integration is strongest when several apparently minor signals are interpreted together.

DACs Support Professionals When Pathways Become Complex

Some situations exceed the coordinating capacity of ordinary professional relationships.

France’s dispositifs d’appui à la coordination, or DACs, provide support for complex health pathways regardless of a person’s age, disability or diagnosis.

Health, social and médico-social professionals can seek DAC support where they judge a pathway to be complex.

The DAC can analyse the situation, help identify appropriate resources, connect professionals, support planning and contribute to reinforced follow-up where needed. Its work is intended to be undertaken in conjunction with the médecin traitant rather than replacing the treating doctor’s role.

This is an important distinction.

The DAC is not designed to take routine coordination away from existing teams. It operates subsidiarily where complexity requires additional support.

Its governance is also deliberately cross-sectoral. Legal provisions require balanced representation from health, social and médico-social sectors and include representation of service users, départements and CPTS.

That design acknowledges that complex pathways cannot be resolved by health services alone.

A person may have an unstable medical condition, unsuitable housing, exhausted family support and difficulty securing sufficient home-care hours at the same time.

Effective coordination requires all four issues to be understood together.

Integration Depends on Knowing What Exists

Coordination is impossible if professionals cannot identify available services.

France’s national Répertoire de l’Offre et des Ressources en santé et accompagnement social et médico-social, or ROR, provides structured information on health, social and médico-social resources.

Its purpose includes helping professionals orient people towards appropriate services and reducing breaks in pathways.

This may sound administrative, but service directories are a core part of operational integration.

A hospital team trying to arrange onward support needs to know what exists locally. A DAC coordinating a complex situation needs reliable information about specialist resources. Primary care professionals need visibility of community and médico-social capacity.

Incorrect or outdated information can create its own form of fragmentation.

The problem is particularly acute where services change frequently or where eligibility differs between organisations.

Integration therefore depends not only on communication between professionals but on the quality of the underlying resource data.

This connects directly with digital records and information governance. Shared digital infrastructure adds value only when the information being exchanged is current, relevant and understandable across organisational boundaries.

Services Autonomie à Domicile Are Designed to Reduce the Divide Between Help and Care

The reform of home support into services autonomie à domicile is one of the most significant structural attempts to improve integration around older people living at home.

Historically, assistance with daily living and nursing care could involve separate service structures. The SAD reform reorganised previous SAAD, SSIAD and SPASAD arrangements around a more coherent model.

By the end of the transition period in December 2025, services were required to align with the new framework.

A SAD can combine help, accompaniment and nursing care directly, or it can organise an appropriate response to nursing needs through coordination with other professionals or services.

The ambition is straightforward: a person should not have to act as the principal coordinator between organisations delivering closely connected forms of support.

In practice, the distinction still matters because integration does not mean that every SAD employs every professional required.

Where nursing is provided through another organisation or independent professionals, responsibility for coordination becomes crucial.

Who identifies a change in condition? Who contacts the nurse? Who knows that medication has changed? Who informs the aide à domicile that mobility has deteriorated?

The stronger service model makes those connections explicit.

Organisations exploring similar coordination risks can use the Governance Maturity Assessment to test whether responsibilities, information flows and escalation routes remain clear across organisational boundaries. The framework does not replicate French legal requirements, but it can help expose ambiguity in shared-care arrangements.

Operational scenario: Home support sees deterioration before the health system does

An aide à domicile notices that an older man with heart failure has become noticeably more breathless over several visits. His ankles are swollen, he is eating less and appears unusually tired.

The worker is not responsible for diagnosing the problem.

But the observation is clinically significant.

In a poorly connected system, it may remain in a home-care note until the person deteriorates sufficiently to call emergency services.

In an integrated SAD pathway, the worker knows how to escalate the observation. A nurse or coordinating professional reviews the concern, the médecin traitant is informed where appropriate and the person’s clinical situation can be assessed before it becomes an emergency.

The operational control is simple but important: non-clinical staff need routes for turning observations into clinical attention without being expected to make clinical decisions themselves.

This is one reason why integration cannot be reduced to organisational charts. The real test is whether information moves quickly enough to change what happens to the person.

EHPADs Are Both Homes and Health-System Partners

EHPADs occupy another important boundary between health care and long-term care.

Residents often have multimorbidity, frailty, cognitive impairment and complex medication regimens. Many also require palliative or end-of-life support.

The médecin coordonnateur has an important role in organising medical coordination within the establishment, but residents continue to interact with external health professionals and hospitals.

This creates multiple interfaces: between the EHPAD and the resident’s médecin traitant, community and specialist clinicians, emergency services, pharmacies and hospital teams.

The effectiveness of these relationships affects whether deterioration can be managed in place or leads to hospital transfer.

France is also strengthening the information available about medical activity within EHPADs. In 2026, the national framework for the Rapport d’Activités Médicales Annuel, or RAMA, is being modernised and harmonised, with structured information intended to support both establishment-level improvement and territorial understanding by ARS, départements and national bodies.

This illustrates an important shift in integration policy: data generated within residential care can help inform wider health-system planning rather than remaining inside individual establishments.

Hospitals Remain Critical Integration Points

For many older people, hospital is where fragmentation becomes most visible.

An acute admission may be triggered by pneumonia, a fall or medication problem, but the hospital team may discover much wider issues: declining mobility, cognitive impairment, carer exhaustion, insufficient home support or an unsafe living environment.

Hospital treatment can address the immediate clinical problem without resolving those underlying conditions.

This is why links between hospitals, primary care and the médico-social sector matter so much.

The challenge is particularly acute for people with multiple conditions, because their recovery depends on continuity after the acute episode.

France continues to examine how alternatives to emergency departments and stronger downstream pathways can respond to population ageing and multimorbidity. A national report delivered to the health minister in July 2026 placed particular emphasis on alternatives to emergency attendance and improved pathways following urgent care.

That policy direction reinforces a wider point: hospital flow cannot be solved solely inside hospitals.

Community health capacity, home care, rehabilitation, EHPAD support and primary-care follow-up all affect whether people can move safely through the system.

Article 22 in this France series examines hospital discharge and care transitions in depth. For integration policy more broadly, the important issue is that hospitals need reliable relationships with the services people return to, not merely discharge destinations on a list.

Shared Information Is the Infrastructure of Integration

Coordination structures cannot compensate indefinitely for fragmented information.

Professionals need appropriate access to relevant information about the person’s health, functional needs, treatment and support arrangements while respecting confidentiality and data-protection requirements.

France’s DAC framework explicitly requires a shared information system within each DAC and provides for information exchange with professionals involved in the person’s care under applicable legal safeguards.

This demonstrates how strongly digital infrastructure and integration are connected.

Yet interoperability involves more than technical connectivity.

Different sectors record different things.

A hospital may focus on diagnosis, tests and treatment. A home-care service may record whether the person ate, transferred safely or appeared confused. An EHPAD may hold information about behaviour, social participation and patterns of deterioration. A département may hold information about assessed autonomy needs and the APA plan.

All of these can be relevant.

The integration challenge is to exchange enough information to support safe decisions without creating uncontrolled access or overwhelming professionals with data.

This is why interoperability and system integration should be understood as a service-design issue as well as a technical one.

Organisations planning cross-system digital change can use the Digital Transformation Readiness Assessment to examine whether governance, information security, workforce adoption and technology capability are developing together.

Families Frequently Become the Unofficial Integration Layer

Formal systems often underestimate how much coordination is performed by relatives.

A daughter may know which specialist prescribed a medicine, tell the hospital what the home-care service does, contact the médecin traitant after discharge and explain new instructions to an older parent.

This contribution can be invaluable.

But integration should not depend on having a confident, available family member capable of managing multiple organisations.

Some older people live alone. Others have relatives living far away or balancing employment and their own health needs. Family relationships may be complex or strained.

Where services assume that a relative will transfer information or organise appointments, hidden inequality emerges.

The person with a highly engaged family receives better informal coordination than the person without one.

Good integration therefore includes families where the person wishes this while keeping professional responsibility clear.

This principle aligns with family partnership and carer support. Carers should be recognised as partners with legitimate knowledge and support needs, not treated as unpaid case managers filling gaps between organisations.

Operational scenario: The daughter is holding the pathway together

An older woman with dementia, arthritis and chronic kidney disease is supported at home. Her daughter attends most medical appointments and keeps a handwritten list of medicines because different professionals do not always have identical information.

After a short hospital admission, medication is changed. The discharge information reaches the médecin traitant, but the daughter is unsure whether the home-care workers or community nurse know about the change.

She telephones each service herself.

The immediate problem is solved because she is organised and persistent.

But the pathway is fragile.

If she becomes ill or unavailable, the system loses its informal coordinator.

A stronger arrangement clarifies which professional is responsible for communicating medication changes, how the SAD receives clinically relevant information and how the family can raise concerns without being expected to distribute records manually.

The lesson is not that family involvement should reduce. It is that professional integration should remain functional even when family coordination is absent.

Integration Needs Clear Ownership of Escalation

Shared working can create its own risk if everybody is involved but nobody is clearly responsible.

This is particularly important when an older person begins to deteriorate.

A home-care worker may identify increasing confusion. A community nurse may observe dehydration. A daughter may report night-time wandering. The GP may know about recurrent urinary infections.

Each piece of information matters.

But integration requires somebody to determine whether these signals collectively require a clinical review, revised support, urgent assessment or longer-term reassessment.

Governance therefore needs explicit escalation routes.

These do not have to place one organisation permanently in control of the whole person’s life. Responsibility can change with the situation.

A medical deterioration may require the médecin traitant or emergency services to lead. A change in autonomy may require département reassessment. A particularly complex cross-sector situation may justify DAC involvement.

The key is that the pathway does not depend on professionals guessing who should act.

This connects with wider decision-making and escalation principles: integrated care needs explicit thresholds for moving concerns across organisational boundaries.

Workforce Skills Determine Whether Integration Happens in Practice

Integration is frequently described through institutions, but much of it is performed by individual workers.

Aides à domicile need to recognise and escalate changes without moving beyond their competence. Nurses need to understand the social environment around clinical needs. Hospital professionals need to understand what home-care services can realistically deliver. Primary-care teams need familiarity with local autonomy and support structures.

Coordination therefore requires cross-sector literacy.

Professionals do not need to become experts in every part of the system, but they need to know enough to identify when another sector should become involved.

This is particularly important as France’s population ages and more people live with multiple long-term conditions alongside functional limitations.

Workforce pressure can also undermine integration.

If teams are continuously filling vacancies, coordinating meetings and follow-up calls may be treated as optional activity. Yet the absence of coordination can create more work later through duplicated assessments, avoidable deterioration and crisis interventions.

This makes older people’s workforce competence part of integration policy rather than a separate staffing issue.

Integration Should Be Measured Through Outcomes, Not Meetings

A system can create multidisciplinary meetings, partnership agreements and coordination structures without improving the person’s experience.

Integration therefore needs evidence.

Useful measures are those that reveal whether the pathway is becoming more coherent.

• Are people repeatedly supplying the same information to different organisations?
• Are medication changes reaching the professionals who need to know?
• Are avoidable hospital transfers decreasing?
• Are complex situations identified earlier?
• Are care plans revised when health or functional needs change?
• Are professionals receiving feedback after referrals?
• Are people and carers able to identify who to contact when circumstances change?

No single metric proves integration.

The stronger approach combines process measures with outcomes and lived experience.

For example, referral volume into a DAC says little by itself. The more important question is whether reinforced coordination resolves recurrent pathway problems or merely adds another organisation to the case.

Providers and system partners examining comparable evidence can use the Quality Dashboard Builder to structure measures around continuity, escalation, hospital use, response times and unresolved pathway risks.

Territorial Variation Makes Integration a Local Governance Challenge

France’s integration infrastructure does not operate identically everywhere.

CPTS maturity varies. Primary-care density differs. Rural areas may have fewer professionals. Some territories have well-established relationships between hospitals and médico-social services, while others remain more fragmented.

DACs also operate within different local ecosystems.

This means national policy can establish the architecture without guaranteeing identical implementation.

ARS and départements therefore have an important role in understanding where local pathways repeatedly break down.

The Service public départemental de l’autonomie adds another potentially important layer. Its purpose includes making autonomy pathways easier to navigate and improving coordination between organisations serving older people, disabled people and carers.

The strongest territorial approach is one in which these different mechanisms complement rather than duplicate one another.

The SPDA can strengthen access and navigation. CPTS can organise territorial health-professional pathways. DACs can support complex situations. SADs can integrate help and care at home. Hospitals and EHPADs retain their own responsibilities.

The governance challenge is to ensure that each organisation understands where its role begins and ends.

Operational scenario: A complex rural pathway needs coordination, not another referral

A 79-year-old man lives in a rural commune with chronic respiratory disease, reduced mobility and mild cognitive impairment. His wife provides most daily support but has recently undergone surgery herself.

The médecin traitant knows the couple well but cannot resolve every practical issue. The local SAD can provide some assistance, although nursing input comes from separate professionals. The nearest hospital is 35 kilometres away.

Following two episodes of breathlessness and growing concern about medication management, several professionals become involved.

The risk is that each responds within their own remit: the GP adjusts treatment, the nurse monitors symptoms, the SAD changes visit times and the family asks the département about additional help.

A DAC referral is appropriate because the problem is the interaction between all these needs.

The coordination process brings the information together, clarifies who is following the respiratory condition, identifies the support required while the wife recovers and establishes what should trigger urgent escalation.

The outcome is not a new permanent service. It is a pathway in which existing services have clearer responsibilities.

This illustrates the strongest purpose of integration: using coordination selectively to make the existing system work as a coherent whole.

Technology Can Support Integration but Cannot Substitute for Relationships

Digital records, shared directories, telehealth and interoperable systems can make coordination faster and more reliable.

They can reduce repeated data entry, allow remote specialist input and make changes in risk more visible.

Artificial intelligence may increasingly assist with identifying patterns in deterioration, missed appointments or service use, although such applications require careful governance and remain uneven in maturity.

Technology nevertheless solves only part of the integration problem.

A shared record does not determine who is responsible for acting on new information.

A digital alert is useful only if somebody sees it and has authority to respond.

Interoperability cannot compensate for incompatible organisational incentives or uncertainty about roles.

The strongest digital model therefore supports professional relationships rather than attempting to replace them.

France’s experience illustrates a wider principle: technical connectivity, operational responsibility and trust need to develop together.

International Learning: Integration Is a Function, Not an Organisation

France offers an important lesson for countries trying to integrate health and long-term care.

The instinctive response to fragmentation is often to create a new coordinating organisation.

France already has several such structures, and each has a legitimate purpose.

But the existence of coordination bodies does not itself create an integrated pathway.

The transferable lesson lies in treating integration as a function that must occur wherever responsibility changes.

A hospital must connect safely with community services. A home-care worker must be able to escalate clinical concerns. Primary care needs routes into autonomy support. An EHPAD must remain linked to external health expertise. Families need understandable points of contact.

Different countries may organise those functions through municipalities, insurers, integrated care organisations or regional authorities rather than French ARS, départements, CPTS and DACs.

The institutional form is therefore less transferable than the underlying design principles:

• clear responsibility at transition points;
• shared access to relevant information;
• coordination proportional to complexity;
• territorial knowledge of available services;
• and evidence that integration improves continuity for the person.

Systems that achieve those functions may look very different administratively while solving the same operational problem.

Conclusion

France has moved considerably beyond viewing integration as a simple relationship between hospitals and primary care. Its ageing population increasingly requires coordination across health, social and médico-social boundaries, involving médecins traitants, community professionals, CPTS, DACs, services autonomie à domicile, EHPADs, départements, ARS and families.

The architecture is substantial. The harder task is making it feel simple from the perspective of the person.

That requires more than additional structures. Integration becomes meaningful when deterioration identified in home care reaches the right clinician, when hospital information follows the person, when primary care can access autonomy support, when complex situations receive reinforced coordination and when families are partners rather than the system’s default messengers.

France’s strongest opportunity lies in connecting its existing infrastructure more reliably. Shared information, mature territorial relationships, clear escalation routes and better outcome evidence can reduce the distance between organisational coordination and lived continuity.

As health needs, frailty and loss of autonomy increasingly overlap, no single part of the system will be able to manage ageing alone. France’s long-term success will depend on whether national reforms translate into local pathways where responsibility follows the person rather than stopping at institutional boundaries. Integration, ultimately, is not achieved when organisations agree to work together. It is achieved when an older person no longer has to understand where one system ends and another begins.