Integrated Health and Social Care in Lithuania: Bridging the Divide Between Systems

An older person recovering from a stroke may need nursing, rehabilitation, medication review, help washing and dressing, meal preparation, mobility assistance and support for a spouse who has suddenly become a carer. To the person, these needs form one life situation. Within Lithuania’s public systems, however, they may involve healthcare organisations, compulsory health-insurance funding, municipal social services, different assessments and several professional teams.

That divide is one of the central issues in Lithuania’s long-term care reform. The country has developed integrated home-care initiatives for more than a decade and has more recently strengthened the legal, workforce and infrastructure foundations for a more coherent long-term care model. Important progress has been made, including greater emphasis on care at home, multidisciplinary provision and new arrangements for integrated services. Yet the comprehensive model remains under implementation rather than representing a fully unified national system.

This eighth article in the Lithuania Ageing, Long-Term Care & Community Support Knowledge Hub examines what integration means in operational terms. It focuses not on merging every organisation, but on whether people can move across health, nursing and social support without separate systems becoming gaps in care, duplicated work or responsibilities that families are expected to reconcile themselves.

Lithuania’s integration challenge begins with institutional separation

Lithuania’s health and social sectors developed around different responsibilities, legislation, funding routes and professional traditions.

The Ministry of Health shapes healthcare policy, while compulsory health insurance finances a substantial proportion of covered health services through the National Health Insurance Fund. Primary healthcare organisations, hospitals, nursing services and other health providers operate within this architecture.

Social services sit within another framework. The Ministry of Social Security and Labour shapes social policy, while municipalities assess social-service needs and organise much of the practical support delivered in homes, day services and residential settings.

These arrangements are not inherently irrational. Health and social care require different professional competencies and forms of accountability. The integration problem arises because people with long-term needs frequently require both at the same time.

A nurse can treat a wound but may not be responsible for whether the person can prepare food. A municipal social worker can organise help with everyday living but does not replace clinical assessment. A hospital can decide that acute treatment is complete without having control over the availability of social support after discharge.

The result is a system in which each component can act appropriately within its own remit while the combined pathway remains difficult.

This is why organisational structure and accountability matter so strongly. Integration depends on knowing not only who is responsible for each component, but who notices when the components no longer form a sustainable whole.

Integrated care has a longer history in Lithuania than current reform alone

Lithuania’s effort to bring nursing and social services closer together did not begin with the latest reform cycle.

Policy work on combined nursing and social support developed during the 2000s, followed by an Action Plan for the Development of Integrated Care from 2012. Early pilot projects supported multidisciplinary home-based teams, allowing municipalities to develop approaches suited to their local context.

Subsequent expansion brought integrated-care projects to almost all Lithuanian municipalities. These initiatives helped establish an important practical principle: people with substantial needs can be supported by mobile multidisciplinary teams in their own homes rather than receiving nursing and social services only through separate institutional pathways.

European investment played an important role in enabling that development, particularly in building community capacity and testing models that required cooperation across traditional boundaries.

The experience also demonstrated that pilot integration and system integration are different achievements.

A multidisciplinary project can coordinate care effectively for the people enrolled within it while wider eligibility, funding, information systems and national governance remain separated. The next stage therefore requires integration to become part of ordinary system architecture rather than depending mainly on particular projects or local relationships.

Integrated assistance brought coordination into people’s homes

Integrated assistance is one of the clearest Lithuanian examples of health and social care being organised around combined need.

The model has typically brought together nursing and social-care functions in the home, often through multidisciplinary mobile teams. Depending on arrangements and individual needs, teams may draw on nurses, nursing assistants, social workers, individual-care workers and rehabilitation-related professionals.

This approach matters because home care creates a particularly strong need for coordination. In an institution, multiple professionals operate within one physical organisation. At home, the person becomes the point at which separate services meet.

A well-designed integrated pathway should therefore make several things easier:

• identifying health and social needs as parts of one situation;
• coordinating visit timing so that different workers complement rather than duplicate one another;
• recognising changes that require another professional response;
• supporting family carers without transferring professional duties to them;
• reviewing whether the combined package remains sustainable; and
• escalating when the person requires a different level or setting of care.

The wider principle aligns with interoperability and system integration. Integration is not simply a meeting between professionals. It is a service design in which the actions of one part of the system make sense in relation to the others.

Scenario: one person, two assessments and three providers

An 82-year-old man lives with his wife after a stroke. He can walk short distances but needs assistance with bathing and dressing. He also requires ongoing nursing, physiotherapy and monitoring of several chronic conditions.

The healthcare system assesses his clinical requirements. The municipality separately assesses the need for social services. His wife attends both processes and repeatedly explains the same daily circumstances.

Each assessment is defensible within its own framework. The problem appears later.

Nursing visits are organised during the morning. Social assistance is scheduled separately and occasionally arrives at almost the same time, while no formal support is available during another period when his wife finds transfers most difficult. Physiotherapy recommendations are not always visible to the social-care workers helping him move.

A stronger integrated response looks at the household timetable rather than the individual services. Nursing, rehabilitation and social support remain professionally distinct but are planned around complementary objectives. Staff know whom to contact when mobility changes. The wife understands which professional deals with which issue and whom to approach if the overall arrangement becomes unsustainable.

Review then considers the combined result: is he regaining function, remaining safe, avoiding preventable deterioration and receiving enough support without his wife becoming exhausted?

The scenario illustrates the central integration test. The system does not need one worker to perform every task. It needs multiple workers to function as one pathway.

Separate needs assessments remain a structural barrier

Assessment is one of the most significant points at which health and social systems can either integrate or reproduce fragmentation.

Historically, Lithuania has used different mechanisms for determining health-related home nursing needs and social-service needs. The criteria, professional decision-makers and information available to assessors have differed.

There are legitimate reasons for specialist assessments. Clinical need requires healthcare expertise, while social-service assessment needs to consider daily functioning, family circumstances and the environment.

The problem arises when specialist assessment becomes duplicated assessment.

The person may provide the same background information repeatedly. One assessor may not be able to see services already being received through another system. Changes identified in healthcare may not automatically alter a social-support package.

A more integrated model does not necessarily require replacing every specialist tool with one universal form. It requires a common core picture of need and a reliable method for converting that picture into coordinated decisions.

This is where care planning and review become more important than administrative assessment alone. The purpose of assessment is to create and maintain an appropriate support arrangement, not merely establish eligibility for one programme.

A single point of access is valuable only if the system behind it is connected

Integrated-care reform often proposes a “single entry point” or “one-stop” approach. For people and families, the attraction is obvious: they should not need to understand ministerial or funding architecture simply to ask for help.

Lithuania’s developing long-term care model has increasingly moved towards this concept, with the objective of making organisation, provision and financing easier to navigate.

Yet a single telephone number or administrative office does not itself create integrated care.

The point of access needs authority and information behind it. Staff must understand which assessments are required, which organisations can respond, what the person is already receiving and how needs should be escalated when they cross sectors.

Otherwise, a single front door merely distributes people back into unchanged silos.

The stronger model treats navigation as a continuing function. Some people with stable needs may need little coordination after support begins. Others with dementia, frailty or complex disability may require active care coordination because their needs and services change repeatedly.

Funding still shapes whether integration is operationally attractive

Lithuania’s integration challenge is not solely organisational. Health-related long-term care and social long-term care have historically been financed through different routes.

Healthcare is principally connected to the compulsory health-insurance system. Social services draw on state and municipal resources and can involve personal contributions depending on the service and individual circumstances.

These separate funding structures can create cost-shifting incentives.

A municipality that invests in intensive social support at home may help prevent hospital use, but some of the financial benefit appears in the healthcare system. A healthcare provider may discharge a person efficiently but the municipality then bears the cost of increased social support. Strong rehabilitation can reduce future dependency, but the resulting benefits may be spread across several public budgets.

This does not mean organisations deliberately avoid integration. It means financial accountability can make each institution more visible for its own expenditure than for the combined cost of the person’s pathway.

Lithuania’s reform debate has therefore considered clearer long-term care financing, including the principle of pooling or coordinating resources more systematically. A comprehensive one-stop model for organisation, delivery and financing remains under development, with further implementation expected beyond the current reform period.

Financial integration needs careful design. A pooled resource requires decisions about who contributes, who controls it, how allocation responds to need and what happens when expenditure exceeds assumptions.

The transferable principle is simpler: services are harder to integrate when the financial system rewards each actor for optimising only its own part.

Hospital discharge is where fragmentation becomes immediately visible

Few pathways expose the relationship between healthcare and social support more clearly than hospital discharge.

A person can be medically ready to leave hospital while still being functionally unable to return safely to their previous routine. They may require rehabilitation, nursing, social care, equipment or substantial family assistance.

Where those components are organised sequentially, the system can lose time.

The hospital completes treatment, another team then assesses community nursing, the municipality begins a social-service process and family members attempt to bridge whatever gap remains. Each organisation may work within legitimate procedures while the overall transition remains fragile.

This is why the principles behind hospital discharge and reablement are so important to integrated long-term care.

A stronger pathway begins before discharge. Functional change is identified early, relevant social and healthcare teams receive sufficient information, equipment or rehabilitation needs are considered, and the initial community package can change as recovery progresses.

The objective is not simply faster discharge. It is appropriate discharge that does not transfer unresolved risk into the home.

Scenario: hospital efficiency creates community risk

A 76-year-old woman is admitted following a hip fracture. Surgery is successful and she no longer needs acute hospital treatment. Before the fall she lived alone and managed independently.

She can now walk with assistance but cannot yet bathe safely or prepare meals. Her son lives nearby but works full-time.

If discharge is judged only through the healthcare lens, returning home appears possible because no further acute treatment is required. If the municipality begins assessment only after she arrives home, her son may become the temporary care package.

An integrated transition identifies the social and functional consequences before discharge. Rehabilitation continues, temporary social assistance is arranged and appropriate equipment is in place. The son remains involved but is not treated as the default provider of daily care.

Most importantly, the package is explicitly temporary and reviewed. As she recovers, support can reduce. If recovery stalls, additional assessment can occur before the arrangement deteriorates into crisis.

Governance should also aggregate similar cases. If people repeatedly wait in hospital because community services are unavailable, the problem is not merely discharge practice. If people repeatedly return to hospital because support began too late, the community system requires attention.

Integration turns those individual transitions into shared system evidence.

Workforce integration is more than creating multidisciplinary teams

Lithuania’s integrated-care ambitions face the same workforce constraint affecting the rest of its long-term care system. Population ageing is increasing need while healthcare and social-care organisations compete for scarce labour.

Multidisciplinary working can improve productivity by allocating tasks to the appropriate skill level, but it also requires new competencies.

A nurse working in a home-based team needs to understand how municipal social support fits around clinical care. A social worker needs to recognise when changing function or behaviour warrants healthcare escalation. Individual-care workers need clear boundaries around tasks they can and cannot undertake.

Team members also need time to coordinate. Integration cannot rely on workers performing full independent caseloads and then collaborating informally in whatever time remains.

Future workforce planning therefore needs to consider:

• the combined health and social skill mix required in community teams;
• which tasks genuinely require particular professional qualifications;
• where delegation is safe and supported by competence;
• who coordinates people with several simultaneous services;
• how rural teams share scarce specialists; and
• how integrated roles develop credible career pathways.

This makes wider workforce planning inseparable from integration policy.

Organisations examining comparable system pressures can use the Digital Twin Scenario Modeller to test how changes in demand, staffing and service design affect capacity. It is not a Lithuanian workforce-planning instrument, but the scenario principle matters: an integrated model is only credible if the workforce assumptions beneath it are deliverable.

Care coordination needs to be treated as real work

Fragmented systems often depend on an invisible coordinator. Sometimes that person is a social worker or nurse. Frequently it is a spouse, daughter or son.

The family member remembers appointments, explains medication changes, contacts the municipality, notices that one service has stopped and tells a new professional what another professional recommended.

That labour is easy to overlook because it is not recorded as a care service.

Integrated long-term care should reduce the amount of coordination that has to be performed privately by families.

This is particularly relevant where needs are complex or unstable. A designated professional coordinating the pathway can help maintain a current picture of support, ensure reviews occur and resolve gaps between organisations.

Not every person requires intensive case management. Creating an expensive coordination layer around straightforward care can itself add bureaucracy. The stronger model matches coordination intensity to complexity.

For people with several services, repeated transitions or limited informal support, care coordination should be recognised as a substantive function rather than expected to emerge automatically from goodwill between professionals.

Families need integration because they experience every boundary

Families often understand fragmentation more clearly than institutions because they deal with its cumulative effects.

They notice that two teams ask the same questions. They learn that an issue belongs to the municipality rather than the healthcare provider only after contacting the wrong organisation. They discover that a relative is technically eligible for support but that it cannot begin immediately.

Strong family partnership and carer support therefore provide an important measure of integration.

Families should know who is involved, whom to contact and what they are expected to provide themselves. Their own capacity also needs to form part of planning.

An integrated system should not use family involvement as the mechanism that makes fragmented services appear coordinated.

Digital integration is one of Lithuania’s largest opportunities

Lithuania has strong national digital-government capability and substantial healthcare digitalisation. This provides an important foundation for integrated care.

Historically, however, health and social-service information systems have been separated. Municipal social-service information and healthcare records have not automatically produced a shared picture of long-term care.

This limits both individual coordination and system intelligence.

If municipal assessors cannot easily see relevant healthcare services, they may plan social support without understanding the complete package. If healthcare teams cannot see important social circumstances, clinical decisions may overlook practical barriers at home.

At national level, separate data also make it difficult to establish how many people receive both health and social long-term care rather than counting each service independently.

The stronger opportunity is not unrestricted access to every record. Privacy and professional relevance matter. The objective is appropriate interoperability: authorised people can see the information required for the decision they are making.

Organisations examining the same transformation challenge can use the Digital Transformation Readiness Assessment to consider whether governance, workforce, resilience and digital capability are aligned. Technology does not create integration by itself; it can only make an agreed integrated process easier to operate.

Scenario: shared data changes a repeated assessment into a coordinated decision

An older woman receives outpatient nursing following deterioration in a chronic condition. Her nurse notices that she has begun struggling with food preparation and that her home appears increasingly difficult to manage.

Under a fragmented pathway, the nurse advises the family to contact municipal social services. The family begins a new process, repeating much of the same background information. The social worker then has limited visibility over the current nursing plan.

A more connected process allows the relevant social-service team to receive an appropriate referral with consent and access the information necessary to understand why support is being requested. The municipal assessment still performs its own legitimate function, but it does not begin without context.

The resulting care plan can then account for nursing visits already taking place rather than unintentionally duplicating them. If social-care workers later identify further deterioration, information can travel back through the agreed health pathway.

This does not require every professional to see every piece of information. It requires clarity about what is relevant, how it is shared and who acts on it.

At governance level, connected data also allow decision-makers to see that the person receives both health and social services, making total long-term care demand more visible.

The scenario demonstrates why digital integration should be measured by better decisions rather than the number of systems technically connected.

Geographic variation can make integration easier in one municipality than another

Lithuania’s integrated-care model must operate across 60 municipalities with very different populations, labour markets and service infrastructures.

Large urban areas may have multiple healthcare and social-service providers, creating coordination complexity but also greater service choice. Smaller rural municipalities can have fewer organisations, which may make personal professional relationships easier while limiting the actual services available.

Neither setting is automatically more integrated.

A rural team may know its health colleagues personally but lack access to rehabilitation or specialist capacity. An urban municipality may have extensive provision but require stronger formal coordination because professionals work across large organisations.

Intermunicipal cooperation can help where scale is insufficient. Shared specialist teams or cross-municipal services can expand access without each locality building identical provision.

Yet integrated governance becomes more complex when municipal, health-provider and intermunicipal boundaries overlap. Responsibility for assessment, financing, complaints and service continuity must remain visible.

The objective should therefore be comparable access through locally appropriate integration, not identical organisational structures everywhere.

Integration should improve quality, not simply reduce duplication

Administrative efficiency is one benefit of integration, but it is not its ultimate purpose.

A system can reduce duplicate forms while still deliver poor care. The stronger test is whether coordination improves outcomes.

Relevant evidence might include whether people:

• receive support sooner after needs are identified;
• experience fewer unnecessary assessments or hand-offs;
• avoid preventable hospital admission or readmission;
• maintain function and independence for longer;
• experience fewer gaps between nursing and social support;
• have families carrying a sustainable rather than hidden level of care; and
• understand who is responsible when circumstances change.

Quality data also need to expose unintended consequences. Faster discharge is not an improvement if readmission rises. Lower institutional use is not automatically success if family burden becomes unsustainable. More home services do not necessarily mean better integration if each service operates independently.

The Quality Dashboard Builder can help organisations structure equivalent combinations of access, workforce, quality and outcome indicators. It does not reproduce Lithuania’s national monitoring arrangements; its relevance is the wider governance principle that integrated care needs integrated evidence.

Governance must make shared outcomes somebody’s responsibility

Integration can create an accountability paradox. More organisations become involved in the person’s care, but responsibility for the combined outcome can become less clear.

The solution is not to erase professional or institutional accountability. A healthcare provider remains responsible for its clinical practice. A municipality remains responsible for its social-service functions. A provider remains responsible for the quality of the service it delivers.

Integrated governance adds another level: how do those organisations know that the pathway between them works?

This requires shared visibility over recurring problems such as delayed starts, failed referrals, duplicate assessment, hospital readmission and gaps in service coverage.

Organisations considering comparable multi-agency governance can use the Governance Maturity Assessment to test whether roles, escalation and assurance remain sufficiently clear. It is not a Lithuanian governance standard, but it reflects an internationally relevant principle: collaboration works best when shared responsibility is explicit rather than assumed.

Integrated-care reform remains unfinished

Lithuania has progressed considerably from the position in which integrated home care depended mainly on early pilots. National reforms have expanded outpatient and home-based long-term care capacity, supported multidisciplinary teams and strengthened the conditions for more integrated provision.

Recovery and Resilience Plan reforms also established ambitious objectives for increasing the proportion of long-term care delivered through outpatient, home and day-centre routes, supported by additional specialist teams, day centres and workforce development.

These reforms should not be interpreted as evidence that full integration has already been achieved.

Current European assessment continues to describe the comprehensive integrated long-term care model as under implementation, with the longer-term one-stop approach to organising, delivering and financing services extending beyond the immediate reform period.

The distinction matters because reform milestones can be completed while everyday coordination remains variable.

Lithuania’s next challenge is institutionalisation in the positive sense: making integrated practice part of ordinary financing, information, assessment and workforce arrangements so that it no longer relies mainly on projects or particularly effective local relationships.

The stronger future model connects prevention, rehabilitation and long-term support

Integration should also expand beyond coordinating existing long-term care.

The most sustainable pathway links prevention, primary healthcare, rehabilitation, social support and intensive long-term care so that people do not move unnecessarily towards higher dependency.

A person leaving hospital may need short-term rehabilitation rather than a permanent increase in social care. An older person beginning to struggle at home may benefit from environmental adaptation and prevention before daily personal assistance becomes necessary.

These interventions cross organisational boundaries but have a common objective: maintaining function.

This is where integration can contribute to financial sustainability as well as better experience. It allows the system to consider the person’s trajectory instead of financing isolated episodes.

Outcome evidence then becomes crucial. Lithuania needs to understand whether investment in coordinated home and community services changes institutionalisation, hospital use, independence and caregiver burden over time.

That supports wider data quality, metrics and performance management: better integration should leave a measurable trace in both service experience and population outcomes.

What other countries can learn from Lithuania’s integration journey

Lithuania’s institutions reflect its own post-independence development, compulsory health-insurance system, municipal responsibilities and social-services legislation. Another country cannot simply reproduce its integrated-care projects or administrative arrangements.

Its experience nevertheless offers several broader lessons.

First, integration can start locally before the whole national architecture is aligned. Lithuania’s integrated home-care projects demonstrated new ways of working and created practical capability before comprehensive system reform was complete.

Second, successful pilots do not eliminate structural fragmentation. Separate assessments, funding and data can continue to constrain services even when multidisciplinary teams work well.

Third, information sharing is not a technical side issue. A system cannot coordinate effectively if relevant professionals cannot establish what other support the person already receives.

Fourth, integration requires financial attention. Separate funding streams can unintentionally encourage cost transfer even where organisations share the same policy objectives.

Finally, integration should be judged through the person’s experience. Institutional diagrams may remain complex while care feels coordinated, or organisations may be formally linked while families still navigate every boundary themselves.

The transferable lesson lies less in the precise Lithuanian model than in treating integration as a combination of governance, money, workforce, information and daily operational behaviour.

The future test is whether the system becomes simpler for the person

Lithuania’s integrated long-term care reforms are moving in a clear direction: greater home and community provision, stronger multidisciplinary working, more coherent long-term care arrangements and eventually a more unified way of organising and financing support.

The practical test will be whether that architecture becomes simpler where it matters.

An older person should not need to understand which ministry ultimately funds a task before knowing whom to approach. A family should not have to coordinate several professional teams because nobody else holds the combined picture. Municipal and healthcare workers should not recreate information unnecessarily because their systems cannot communicate.

Simplifying the experience does not require simplifying every institution. Health and social care will continue to have different expertise, rules and accountabilities.

The objective is to make complexity manageable inside the system rather than exporting it to the citizen.

Conclusion

Integrated health and social care is one of the most consequential parts of Lithuania’s long-term care transformation. The country has already moved well beyond isolated discussion of integration: multidisciplinary home-care models have developed across municipalities, outpatient long-term care capacity has expanded and recent reforms have created stronger foundations for more coherent provision. Yet the comprehensive integrated model remains a work in progress, particularly where assessment, information, financing and organisational responsibility still follow separate health and social pathways.

The strongest next step is therefore not simply adding more integrated teams. Lithuania needs integration to become embedded in the ordinary operating architecture of care: assessment that builds one usable picture of need, information that follows the person appropriately, financing that reduces incentives for cost shifting, workforce models that recognise coordination as real work and governance that identifies problems occurring between organisations as clearly as problems occurring within them.

Success should ultimately be visible from the person’s perspective. Hospital discharge should lead into a prepared community pathway. Families should support relationships without becoming unpaid system coordinators. Professionals should understand what others are doing and how to respond when needs change.

Lithuania’s experience demonstrates that bridging health and social care is not achieved through one organisational reform. It is achieved when policy, funding, data and professional practice repeatedly produce the same result: different institutions acting around one person as though continuity were a shared responsibility.