Health and Social Care Integration in Italy: Closing the Gaps Between Systems

An older person may be medically stable enough to leave hospital yet unable to wash, prepare food or move safely at home. Another may receive excellent nursing through the Servizio Sanitario Nazionale (SSN) while an exhausted spouse quietly provides twenty or thirty hours of additional support each week. A third may qualify for municipal assistance but still experience repeated hospital admissions because health and social services are responding to different parts of the same problem.

These are not unusual edge cases. They illustrate the central integration challenge within Italian long-term care. The country’s system deliberately distributes responsibilities across the State, Regions and Autonomous Provinces, local health organisations, municipalities, Ambiti Territoriali Sociali (ATS), families and private care arrangements. The Italy Ageing, Long-Term Care & Community Support Knowledge Hub examines how these different components interact across ageing, funding, home care, residential services, workforce and reform.

Integration does not therefore mean creating one national organisation responsible for everything. Italy’s institutional architecture is decentralised and unlikely to become structurally uniform. The stronger policy ambition is to make separate responsibilities work as one coherent pathway around the person.

That ambition has become more explicit through Law No. 33/2023, Legislative Decree No. 29/2024, the development of Punti Unici di Accesso (PUA), unified multidimensional assessment, LEPS for older people who are non-self-sufficient, PNRR territorial-health reforms and the National Plan for Non-Self-Sufficiency 2025–2027. Together, these measures create a stronger framework. Their success, however, depends on implementation across the interfaces where fragmentation has historically been most visible.

Italy’s integration problem begins with divided institutional responsibility

Health and social care in Italy are governed through different systems with different constitutional, financial and operational foundations.

The SSN provides healthcare through nationally defined essential levels of assistance, the Livelli Essenziali di Assistenza (LEA). Regions and Autonomous Provinces organise their regional health systems and determine how territorial services are structured. Local health organisations and districts then deliver or arrange services including home healthcare, rehabilitation and other social-health interventions.

Social assistance operates differently. Municipalities have substantial responsibilities for social services, often working collectively through ATS. Regions shape the wider framework, while national social policy increasingly defines minimum expectations through the Livelli Essenziali delle Prestazioni Sociali (LEPS).

Alongside these systems sit national cash benefits administered by INPS, privately purchased support, the badante workforce and extensive unpaid family care.

For governance purposes, the distinction is legitimate. Healthcare and social assistance need clear responsibilities, funding rules and accountability.

For the person, however, needs do not obey administrative boundaries.

An older man with heart failure may require nursing, help preparing meals, support with mobility and supervision after a hospital discharge. One part of that requirement is clinical, another social, another may be provided by family, and another purchased privately.

The operational challenge is therefore not eliminating institutional boundaries but preventing them from becoming breaks in continuity.

Integration should be measured by the person’s experience, not the organisation chart

Systems often describe themselves as integrated when professionals attend joint meetings, information systems are connected or health and social services share a building.

Those developments can help, but they are not integration in themselves.

For the person, integration is visible when:

• there is a clear route into support;
• assessment considers clinical, functional and social need together;
• professionals understand who is responsible for which intervention;
• care does not stop at an organisational boundary;
• information follows the person appropriately between settings;
• families do not become the default coordinators of fragmented services; and
• changes in need trigger coordinated review rather than separate reassessments.

This is why organisational structure and accountability matter so much in long-term care. Integration is easier to discuss than to govern because shared outcomes often span multiple organisations while accountability remains institution-specific.

Italy’s stronger reform direction is therefore moving beyond informal professional collaboration towards common access points, multidimensional assessment, personalised planning and clearer national expectations.

The challenge is to ensure that these mechanisms change the pathway rather than simply add another layer of process.

PUA are designed to reduce the burden of navigating separate systems

Punti Unici di Accesso are central to Italy’s attempt to create a more coherent entry point for people with complex needs.

The principle is straightforward: an older person or family should not need expert knowledge of municipal, regional, health and social-service structures before they can ask for help.

PUA are intended to support information, orientation, initial assessment and access to more integrated health and social pathways. In the evolving system for older people who are non-self-sufficient, they are linked increasingly with the Case della Comunità and the territorial healthcare architecture established through DM 77/2022 and the PNRR.

The concept becomes especially important when needs span multiple domains.

A hospital may identify that someone cannot return home safely. A general practitioner may notice progressive frailty. A municipality may become aware of an isolated older resident. A family may seek help because dementia has intensified.

Each of those situations should be capable of entering a pathway that sees the whole person rather than sending them repeatedly from one institution to another.

The stronger operational test for a PUA is therefore not simply how many contacts it receives. It is whether people move from first contact to appropriate multidimensional assessment, personalised planning and actual support without unnecessary duplication or abandonment between agencies.

Operational scenario: one front door prevents a fragmented discharge

An 83-year-old woman is admitted to hospital after pneumonia. She recovers clinically, but the admission has left her weaker and less confident walking. Before hospitalisation she lived alone, with her daughter visiting several times each week.

The hospital identifies that she no longer needs acute treatment. The question is whether discharge home is sustainable.

In a fragmented pathway, the health system could arrange nursing follow-up while the daughter separately contacts municipal services, applies for additional help and tries to coordinate transport, meals and practical support.

A more integrated route brings those requirements into one access pathway. The woman’s health, mobility, home environment and family circumstances are considered together. Relevant health professionals determine her clinical and rehabilitation needs, while social-service input examines the practical support required for daily living.

The resulting plan coordinates short-term rehabilitation, appropriate home healthcare and social assistance, with review scheduled because some needs are expected to reduce as recovery progresses.

The daughter remains involved but is not expected to function as the unpaid system coordinator.

The value of integration here is not simply administrative convenience. It improves the probability that the woman returns home with a viable package rather than a set of disconnected interventions.

This links directly with homecare transitions and hospital interfaces. The quality of discharge depends on what happens after the person crosses the hospital threshold.

Multidimensional assessment is the bridge between health and social need

Italy’s move towards stronger multidimensional assessment reflects a fundamental reality: long-term care cannot be allocated safely from diagnosis alone.

A person’s care requirement depends on functional ability, cognition, psychological wellbeing, living environment, family capacity, income circumstances, social isolation and the availability of support as well as medical condition.

Existing regional systems have used multidisciplinary assessment arrangements under different local formulations. Legislative Decree No. 29/2024 seeks to move towards a more unified multidimensional assessment for older people, supported through PUA and UVM.

The reform is particularly significant because assessment itself can become a source of fragmentation. A person may previously have been assessed separately for health, municipal social assistance, disability-related benefits or different service pathways.

A more coherent model should reduce unnecessary duplication while producing a fuller understanding of need.

However, 2026 remains a period of implementation and experimentation rather than evidence that one fully standardised national process is already operating identically everywhere.

This distinction matters. Strong policy architecture creates the opportunity for integration, but professionals still need compatible systems, sufficient workforce and authority to translate assessment into real support.

The Governance Maturity Assessment can help organisations examining similar transformations test whether roles, escalation and implementation are sufficiently clear. It is not an Italian regulatory framework, but its underlying governance principle is useful: integration requires explicit accountability as well as shared ambition.

Personalised planning should convert assessment into one practical pathway

Assessment identifies need. Integration requires those findings to become a coherent plan.

The Piano Assistenziale Individualizzato (PAI) is important because it can connect health, social-health and social interventions around one person rather than leaving each service to operate from a separate logic.

The strongest PAI is not a catalogue of service names. It clarifies objectives, responsibilities, intensity, family involvement, review and what happens when circumstances change.

For an older person with frailty, this may involve ADI, municipal assistance, rehabilitation, equipment, family support and private care. For another person, residential or semi-residential care may be more appropriate.

Personalisation therefore needs more than choice between existing services. It requires the system to understand how different resources combine around the person.

This connects directly with person-centred planning for older people. Integration is strongest when the care pathway is organised around the person’s life rather than around the institutional origin of each intervention.

LEPS are strengthening the social side of integration

One longstanding structural imbalance in Italy has been the stronger national framework around healthcare compared with social assistance.

The SSN operates through nationally defined LEA. Social-service access has historically been more territorially variable, reflecting municipal resources, regional arrangements and local service capacity.

The development of LEPS is therefore strategically important.

For older people who are non-self-sufficient, national policy identifies social-home assistance, social assistance integrated with health services, respite and support for families among the areas requiring stronger minimum guarantees.

ATS are central to this architecture because they provide a territorial level for planning, coordination and implementation that can sit more effectively alongside health districts than very small municipalities acting alone.

The June 2025 interministerial guidelines on more homogeneous ATS organisational models further reinforce this direction.

Yet minimum standards only contribute to integration if the social side of the system has sufficient capacity to deliver them.

A hospital cannot discharge safely into a theoretically available social service that has a long waiting list. A PUA cannot create meaningful integrated care if there are too few social workers or home-support staff to respond.

The continuing strengthening of professional social-service staffing is therefore part of integration policy, not a separate workforce issue.

The National Plan for Non-Self-Sufficiency provides a stronger programming framework

The National Plan for Non-Self-Sufficiency 2025–2027 adds another important layer to Italy’s integration architecture.

Adopted in 2026 alongside allocation of the National Fund for Non-Self-Sufficiency, the Plan provides a structured multi-year framework for social interventions supporting people who are non-self-sufficient and their families.

Approximately €3 billion is allocated across the three-year period, with annual resources approaching €1 billion or more.

The importance of the Plan is not simply the amount of funding. Multi-year programming gives Regions and ATS a more stable framework for developing services and implementing LEPS.

It also reinforces the need to connect social planning with health-system capacity.

A social programme focused on maintaining people at home has implications for ADI, hospital discharge, family care and residential demand. Similarly, expansion of SSN home healthcare changes the level and type of social assistance required around clinical interventions.

The strongest opportunity is therefore to avoid treating health and social funding as independent policy streams.

Integrated planning should ask what combined level of capacity is required in each territory to support older people at home safely and sustainably.

The Digital Twin Scenario Modeller offers organisations a way to explore comparable interactions between demand, workforce and service capacity. It does not model Italian public expenditure, but the underlying scenario-planning discipline is relevant where changing one part of a care system alters pressure elsewhere.

Operational scenario: a social-care gap becomes a health-system problem

A 79-year-old man with diabetes, reduced mobility and mild cognitive impairment lives alone in a suburban municipality. ADI nursing visits are arranged because of a leg ulcer.

Clinically, the nursing intervention is delivered as planned. The wound initially improves.

Over several weeks, however, the nurses notice that the man is eating poorly and sometimes forgets whether he has taken medication. His apartment is becoming increasingly disorganised, and he has stopped attending appointments that require travel.

None of these issues is solved by increasing wound-dressing frequency.

The nursing team raises the wider concerns through the relevant territorial pathway. Municipal social services assess the man’s daily-living needs and identify practical assistance that can reduce the risk of deterioration. His general practitioner reviews his medicines and cognitive changes.

The result is a combined intervention addressing health and social causes rather than repeatedly responding to the wound alone.

If no social support had been available, the likely consequences could have appeared later as a health event: infection, medication error, falls or emergency admission.

This illustrates why health inequalities and prevention are closely connected to social-service capacity. Social need frequently becomes clinically visible only after it has already begun to affect health.

Hospital discharge is one of the clearest tests of integration

Transitions from hospital to home expose institutional boundaries quickly because acute healthcare operates to different timescales from long-term care.

A hospital may determine that someone no longer needs inpatient treatment. That does not automatically mean the person has regained the ability to live independently.

Protected discharge services and integrated assessment therefore play an important role in ensuring that people do not move from intensive hospital support into an unprepared household.

LEPS include social services for protected discharge, reinforcing the principle that social-care capacity is part of safe system flow.

The operational challenge is timing.

Health and social assessment need to begin early enough that necessary services are ready when the person can leave hospital. If municipal support is only considered at the end of the clinical episode, delays become more likely.

Conversely, pressure to improve hospital flow should not result in family members being expected to provide unplanned intensive care simply because no formal support is available.

A strong integrated discharge model therefore needs:

• early identification of people likely to need continuing support;
• multidimensional assessment rather than medical readiness alone;
• clear information about home and family circumstances;
• visibility of ADI and social-service capacity;
• coordinated start dates for relevant interventions; and
• a mechanism for rapid review if the home arrangement begins to fail.

Integration here is not an abstract strategic objective. It directly affects hospital capacity, readmission risk and the person’s ability to recover.

Case della Comunità and COT can strengthen territorial coordination

Italy’s PNRR Mission 6 has accelerated development of territorial health infrastructure through Case della Comunità, Centrali Operative Territoriali (COT), Ospedali di Comunità, home care and telemedicine.

These reforms provide physical and organisational infrastructure around which stronger health-social integration can develop.

Case della Comunità are intended to bring territorial healthcare functions closer to communities and can provide a practical location for integrated access and professional collaboration.

COT support coordination across settings and services, including transitions between hospital, territorial care and home.

The opportunity is substantial because fragmentation frequently occurs not from absence of services but from weak coordination between them.

However, territorial health infrastructure remains primarily part of the health system. Social integration depends on meaningful participation from municipalities and ATS rather than assuming that social functions become integrated automatically because they operate near a health facility.

Physical co-location can help. Shared workflow matters more.

The strongest models will therefore establish agreed referral routes, contact points, information-sharing protocols and joint escalation arrangements around people whose needs cross boundaries.

Funding boundaries can create perverse incentives

Health and social care are funded through different mechanisms. That distinction creates accountability but can also encourage cost-shifting.

A municipality may invest in home assistance that helps prevent hospital use, yet the financial benefit appears mainly in the health system. A Region may expand ADI, but if social support does not increase alongside it, households may have to purchase more private assistance.

Similarly, insufficient community support can lead to earlier residential admission, transferring costs into another part of the system or onto families.

This creates a classic integration problem: the organisation paying for prevention is not always the organisation that captures the financial benefit.

Italy does not necessarily need one pooled national long-term care budget to address this. It does need governance capable of understanding cross-system consequences.

Leaders should be able to ask whether reductions in one service create additional demand elsewhere and whether resource allocation reflects the total care pathway rather than institutional expenditure in isolation.

This is closely connected to assurance and governance. A system can meet separate budget targets while producing poor overall value if costs simply migrate between organisations.

Workforce capacity is the practical limit of integration

Integration requires people, not only structures.

Italy needs sufficient nurses, doctors, rehabilitation professionals, social workers, care workers and other practitioners to deliver the coordinated pathways that policy now envisages.

Workforce shortages can create fragmentation even when institutional relationships are strong.

A UVM may agree a comprehensive care plan, but if there is no available home-support workforce, the social component remains theoretical. A municipality may identify urgent need but lack enough social workers to reassess quickly. A Region may expand ADI coverage but struggle to provide the intensity required for people with complex needs.

Professional boundaries matter as well. Integration should not blur accountability to the point that workers perform tasks outside competence or legal scope.

The objective is coordinated multidisciplinary practice in which different roles contribute clearly defined expertise.

This connects with workforce planning. Integration policy should model the workforce required across the pathway rather than planning each profession independently.

Organisations considering comparable risks can use the Predictive Workforce Risk Module to examine how staffing instability may affect continuity and service capacity. The underlying lesson for Italy is clear: integrated pathways cannot outperform the workforce available to deliver them.

Operational scenario: family care should complement integration, not substitute for it

An 85-year-old woman with advanced frailty lives with her 88-year-old husband. Their daughter visits several evenings each week. ADI provides intermittent clinical support, while the husband manages meals, personal care and supervision throughout most of the day.

The arrangement appears stable in formal records because healthcare visits are completed and no urgent incident has occurred.

During a review, however, the husband explains that he is no longer sleeping properly and has fallen twice himself while helping his wife transfer at night.

This changes the integration problem.

The household does not simply need more health monitoring for the woman. It needs a reassessment of the combined care model. Social services examine additional home support and respite options. Rehabilitation professionals review transfer techniques and equipment. The family discusses which tasks the husband wants to continue providing and which have become unsafe.

The daughter is included in planning without being treated as the default replacement workforce.

The scenario highlights an important principle: informal care can make integrated support possible, but it should not be the invisible resource that closes every formal service gap.

This is why family partnership and carer support must be included in system planning. A pathway that works only while an unpaid carer absorbs unsustainable demand is not genuinely integrated or resilient.

Information sharing determines whether integration survives day-to-day practice

Even well-designed care pathways can fragment if information does not move with the person.

A municipal social worker may identify that a person’s support network has collapsed. A hospital may discharge someone without knowing whether home assistance is active. A nurse may observe cognitive deterioration that affects social-care needs. A family may be telling several professionals the same story because systems cannot share relevant information.

Digital interoperability can help, but integration requires more than technical connection.

Professionals need clarity about what information they are permitted to share, why it is relevant and who is responsible for acting on it.

Data quality also matters. An integrated record containing outdated information can create more risk than separate accurate records.

Italy’s wider digital-health development, including territorial infrastructure and the evolution of the Fascicolo Sanitario Elettronico, creates opportunities for stronger continuity. Social-service integration is more complex because municipal and health systems have different infrastructures and governance arrangements.

The goal should therefore be proportionate information exchange that supports decisions without undermining privacy.

This connects directly with interoperability and system integration. Organisations exploring similar change can use the Digital Transformation Readiness Assessment to test whether technology, workforce adoption and governance are aligned.

Digitalisation should make a fragmented system easier to coordinate, not simply make fragmentation electronic.

Quality measurement needs to cross organisational boundaries

One of the hardest problems in integrated care is determining who owns the outcome.

A health service may meet its ADI activity target. A municipality may deliver every authorised social-care hour. A hospital may reduce length of stay. Yet the person may still experience repeated crises because the combined pathway is poorly coordinated.

Integration therefore requires system-level measures alongside organisational ones.

Useful evidence includes:

• time from identification of need to completed multidimensional assessment;
• time from assessment to actual service start;
• avoidable gaps between hospital discharge and community support;
• repeated emergency use among people already known to territorial services;
• changes in family-carer burden;
• unmet social or healthcare needs despite active care plans; and
• variation in outcomes between territories.

Person and family experience should sit alongside these measures. Administrative data can show that every step occurred; lived experience can reveal that nobody appeared to coordinate them.

This is where data and quality metrics become an integration tool rather than simply a reporting function.

The Quality Dashboard Builder can help organisations structure comparable views of quality, capacity, risk and outcomes. The broader principle is particularly important in Italy: integration should be evidenced through the performance of the combined pathway, not only through separate institutional compliance.

Regional variation makes integration both necessary and difficult

Italy’s decentralised structure means integration cannot be implemented through one identical national operating model.

Regions have different health infrastructures, workforce markets and traditions of social-health organisation. Municipal and ATS capacity varies. Rural and inner areas face different geographic constraints from major cities.

This allows local adaptation, which can be valuable.

It also means that national reform needs sufficiently strong common expectations to prevent integration quality becoming dependent on postcode.

The development of LEPS, more homogeneous ATS models, PUA, UVM and national non-self-sufficiency planning all represent attempts to create a stronger common floor without removing regional responsibility.

The governance challenge is therefore to understand variation rather than eliminate it mechanically.

Some territories may legitimately organise services differently while producing equally strong outcomes. Others may show recurring gaps in access, waiting times or coordination that reflect underlying capacity weakness.

National and regional monitoring should increasingly distinguish between those forms of variation.

Integration should support independence rather than create a larger bureaucracy

There is always a risk that integration reforms become administratively complex.

New assessment tools, coordination meetings, information systems and governance structures can consume professional time without improving the person’s experience.

The strongest test is therefore practical.

Does integration reduce repeated assessment? Does it make responsibility clearer? Does the person receive support sooner? Do professionals spend less time chasing information? Are families required to coordinate fewer institutions? Are preventable crises identified earlier?

If not, integration may exist more strongly in governance documents than in operational reality.

This is why outcomes-focused support should remain central. The purpose of integration is not organisational elegance. It is better continuity, independence, safety and quality of life.

For older people, this often means receiving just enough coordinated support to remain at home without creating unnecessary dependency. For others, good integration may mean recognising earlier that residential, palliative or more intensive support is now appropriate.

A person-centred integrated system is therefore flexible about the setting while remaining consistent about the objective: matching support to changing need.

Future reform should focus on the interfaces that remain weakest

Italy has already created much of the policy architecture required for stronger integration.

Law No. 33/2023 provides a national reform direction for older people. Legislative Decree No. 29/2024 develops assessment and personalised planning. LEPS strengthen the social-service floor. The National Plan for Non-Self-Sufficiency 2025–2027 provides multi-year programming. PNRR Mission 6 has expanded territorial health infrastructure.

The next phase is less about adding another reform label and more about making the existing components work together.

Several interfaces deserve particular attention:

hospital to home, where timing and capacity determine whether discharge is safe;

health to municipal social care, where different funding and information systems can fragment support;

formal services to family care, where hidden burden can sustain an apparently successful pathway;

assessment to provision, where eligibility can be undermined by waiting lists or workforce shortages; and

national standards to regional delivery, where common expectations need to coexist with legitimate local adaptation.

These are the points at which integrated policy becomes either meaningful or symbolic.

What Italy’s integration experience offers internationally

Italy’s model cannot be transplanted directly into countries with different constitutional, insurance or municipal structures. Its experience nevertheless offers several useful principles.

First, integration does not require institutional merger. Separate organisations can produce coherent care when access, assessment, responsibility and information are aligned.

Second, health and social care need comparable strategic weight. Expanding healthcare at home without strengthening everyday support can simply transfer burden to families.

Third, minimum social guarantees matter in decentralised systems because integration is only as strong as the least available part of the pathway.

Fourth, integrated planning should examine costs and outcomes across organisations. Preventive social support may generate value in the health system, while weak community capacity can create expensive hospital or residential demand.

Fifth, families should be partners rather than default system infrastructure.

Finally, integration should be evaluated from the person’s perspective. The most sophisticated organisational architecture has limited value if the individual still has to coordinate the system themselves.

The transferable lesson lies less in Italy’s specific institutions than in the principle that complex needs require shared operational responsibility even where legal and financial responsibility remains divided.

Conclusion

Health and social care integration is one of the defining challenges of Italy’s long-term care system because the needs of older people routinely cross boundaries that institutions still need for governance, finance and accountability. The objective is therefore not to erase those boundaries but to ensure that people do not experience them as gaps in care.

Italy now has a stronger framework for achieving this. PUA can simplify access. Multidimensional assessment can bring clinical, functional and social need into one view. PAI can translate that assessment into personalised support. LEPS and the National Plan for Non-Self-Sufficiency can strengthen the social-service foundation, while PNRR territorial reforms provide new infrastructure for community-based healthcare.

The decisive test is implementation. Integration requires enough professionals to deliver agreed plans, information systems that support rather than obstruct coordination, funding decisions that recognise cross-system consequences and governance capable of identifying when one organisation’s success conceals another part of the pathway failing.

Most importantly, it requires attention to the person and family living between these systems. When health services, social care, community support and family contributions reinforce one another, Italy’s decentralised structure can provide flexible and locally responsive care. When they operate as separate worlds, fragmentation becomes part of the care burden itself. Closing that gap is therefore central to the future sustainability, equity and humanity of Italian long-term care.