Integrated Home Care in Italy: Understanding Assistenza Domiciliare Integrata

An older person returns home after a hospital admission with reduced mobility, multiple medicines and a wound requiring professional treatment. Their family can help with meals and companionship but cannot provide nursing care. Remaining at home therefore depends on something more organised than relatives checking in: healthcare professionals need to reach the person at home, work from a coherent plan and respond when their condition changes.

In Italy, Assistenza Domiciliare Integrata (ADI) is a central mechanism for providing this kind of professional care. It sits within a wider system in which the Servizio Sanitario Nazionale (SSN), Regions and Autonomous Provinces, local health organisations, municipalities, families and private care arrangements all contribute different elements. The Italy Ageing, Long-Term Care & Community Support Knowledge Hub places ADI within that broader architecture of ageing, long-term care and territorial reform.

ADI has become particularly important as Italy pursues the principle of the home as the first place of care through Mission 6 of the Piano Nazionale di Ripresa e Resilienza (PNRR). The national expansion has been substantial: by 2025, more than 1.6 million people aged over 65 had received one or more home-care interventions during the year, exceeding the national PNRR target.

Yet coverage is only the beginning of the policy question. A person counted as receiving home care may have very different needs, professional input and intensity from another person counted in the same headline total. Italy’s next challenge is therefore to convert expansion into consistently useful care: timely assessment, sufficient clinical intensity, multidisciplinary coordination, continuity, reliable workforce capacity and stronger connections between healthcare and the everyday support that allows people to remain at home.

ADI is healthcare delivered at home, not a general domestic-care service

The term integrated home care can create confusion for international readers because different countries place very different activities inside their home-care systems. In Italy, ADI is fundamentally part of healthcare and social-health provision. It is designed for people who are non-self-sufficient, frail, chronically ill or otherwise require qualified professional interventions that can appropriately be delivered at home.

Depending on assessed need and regional organisation, input can include nursing, medical care, rehabilitation and other professional health or social-health interventions. The service is intended to operate through an individual care pathway rather than as a collection of unrelated home visits.

This distinguishes ADI from Servizio di Assistenza Domiciliare (SAD), the social home-assistance arrangements generally organised through municipalities or territorial social-service structures. SAD may support personal and everyday activities, household functioning and social needs. ADI addresses healthcare and social-health requirements through the SSN.

For the person receiving support, however, that institutional distinction can be less important than whether both sides work together. Someone may need a nurse to manage a wound, a physiotherapist to support recovery, help with washing and dressing, meals, medication routines, mobility and supervision. Their life does not divide itself neatly into regional healthcare and municipal social assistance.

This is why homecare service models and pathways need to be understood as complete journeys rather than isolated interventions. ADI can provide an essential clinical component without automatically meeting every need required to sustain the person safely at home.

National entitlement is delivered through regional systems

ADI operates within Italy’s decentralised SSN. National government defines the broad healthcare framework and the Livelli Essenziali di Assistenza (LEA), the essential levels of healthcare that the SSN is required to provide. Regions and Autonomous Provinces organise their respective health services and determine how territorial delivery is structured within national requirements.

Local health organisations and districts then translate those arrangements into operational services. Their names and organisational structures are not identical throughout Italy, which is itself important: ADI is a national concept operating through territorially different systems.

Responsibility can therefore be understood across several layers:

• the State establishes national healthcare guarantees, policy direction and major reform frameworks;
• Regions and Autonomous Provinces organise and fund regional implementation within the SSN;
• local health organisations and districts arrange operational home-care pathways and professional delivery;
• municipalities and territorial social structures may provide complementary social assistance; and
• families and privately employed workers often provide substantial support outside formal ADI hours.

This division allows services to respond to local population characteristics and existing health infrastructure. It also creates variation in access, intensity and organisation.

The governance task is consequently more demanding than establishing a national entitlement. National policy needs to know whether regional implementation is producing sufficiently comparable access and outcomes, while Regions need visibility of variation between their own districts and territories.

Organisations examining comparable multi-level arrangements can use the Governance Maturity Assessment to structure questions about responsibility, oversight and escalation. It is not an Italian regulatory instrument, but the underlying governance principle is directly relevant: decentralisation works best when local discretion is accompanied by clear accountability for results.

Access begins with need, assessment and a care pathway

ADI is not simply a service that a household purchases directly from the SSN because it would prefer professional care at home. Access is connected to assessed health and social-health need and to the regional pathway through which home care is activated.

Routes into assessment can arise from different parts of the system, including hospital discharge, primary care and territorial services. The precise procedure varies by Region and local organisation.

For people with more complex needs, multidimensional assessment is particularly important. A clinically narrow assessment might identify a wound or rehabilitation requirement while missing cognitive impairment, an exhausted spouse, unsafe housing or an inability to manage medicines. Those factors can determine whether home care succeeds.

The resulting care plan should clarify what support is required, which professionals are involved, expected frequency and intensity, objectives and review arrangements. The more complex the person’s needs, the more important it becomes that the plan functions as a coordination mechanism rather than merely an administrative record.

This connects strongly with person-centred planning for older people. A clinically appropriate intervention can still be operationally weak if it does not reflect how the person actually lives, who else provides care and what outcomes matter to them.

Assessment should therefore answer two related questions: what professional care does this person require, and what wider conditions need to exist for that professional care to achieve its intended result?

Operational scenario: discharge home requires more than a nursing referral

An 82-year-old man is medically ready to leave hospital after treatment for an infection and a period of reduced mobility. He lives with his 79-year-old wife. Before admission he walked independently around their apartment; he now needs assistance transferring and has a wound requiring monitoring.

A hospital-to-home pathway that focuses only on discharge could send the relevant clinical information to territorial services and arrange nursing visits. A stronger pathway asks whether the home arrangement as a whole is sustainable.

The local health service activates ADI following assessment. Nursing input is arranged for the wound, and rehabilitation professionals assess mobility and recovery potential. The family doctor remains part of the clinical picture. His wife can provide some support but is not expected to undertake tasks beyond her capability.

The assessment also identifies that the couple needs practical assistance with daily routines. That requirement sits partly outside ADI and requires connection with municipal social support and family arrangements.

The key outcome is not simply that a nurse attended the home. It is that the man remains safely at home, regains function where possible and avoids preventable deterioration or readmission.

This is why ADI matters to hospital and homecare interfaces. A successful discharge is a transfer of responsibility supported by information and capacity, not merely movement from a hospital bed to a domestic address.

The meaning of integration is practical, not organisational

ADI includes the word integrata, but integration should not be assumed simply because the service carries that name.

For the person, integration means that different professional contributions make sense together. The nurse knows what the doctor has changed. Rehabilitation goals are compatible with the person’s daily support. Changes in condition are communicated quickly. The family understands whom to contact. A transition between hospital and home does not require the person to reconstruct their story repeatedly.

At system level, integration also requires connections with services outside the immediate ADI team. Municipal social support, pharmacies, specialist services, palliative care, residential services and privately employed care workers may all affect the same person.

The more organisations involved, the greater the risk that coordination itself becomes an unpaid family responsibility.

Italy’s wider reform direction under Law No. 33/2023 and Legislative Decree No. 29/2024 is relevant because it seeks stronger coordination around older people who are non-self-sufficient. ADI is therefore part of a larger movement towards more coherent assessment and personalised support, rather than a standalone answer to long-term care fragmentation.

The distinction matters operationally. Expanding professional home visits without strengthening coordination can increase activity while leaving the person navigating multiple disconnected systems.

PNRR investment has transformed the scale of the home-care ambition

Mission 6 of the PNRR placed territorial healthcare and home care at the centre of Italy’s post-pandemic health transformation. Investment 1.2, Casa come primo luogo di cura e telemedicina, has supported expansion of home care, Centrali Operative Territoriali (COT) and telemedicine.

The home-care component was designed to increase the number of people aged over 65 receiving care at home substantially from the 2019 baseline. National monitoring through AGENAS uses the Sistema Informativo per l’Assistenza Domiciliare (SIAD) to track the number of over-65s receiving one or more relevant home-care interventions.

By 2025, 1,625,785 people aged over 65 had been taken into care with one or more home interventions during the year, equivalent to 11.3% of the over-65 population and above the monitored national target.

This is a major expansion in reach.

It also changes the governance question. During rapid expansion, the immediate metric is understandably coverage. Once the numerical target has been achieved, policy attention needs increasingly to examine what sits underneath it.

How quickly did support start? How many contacts did the person receive? What professional skill mix was available? How long did the episode last? Did the intervention prevent deterioration? Was family burden reduced? Did people in different Regions receive materially different intensity for similar needs?

The shift from counting access towards understanding value is essential if ADI is to mature from an expansion programme into a sustainable pillar of Italian long-term care.

Coverage and intensity are different measures of home-care capacity

A headline percentage of older people receiving home care is useful, but it cannot by itself describe the strength of a home-care system.

One person may receive a limited number of professional contacts following a short-term clinical episode. Another may require multidisciplinary intervention over many months. Both can appear in a coverage measure.

This creates an important analytical distinction between reach and intensity.

Reach asks how many people receive the service. Intensity asks how much clinically appropriate care each person receives, for how long, from which professionals and with what result.

Italy needs both. A home-care system that reaches too few people cannot support population ageing effectively. But a system that reaches many people with insufficient intensity may struggle to substitute meaningfully for hospital or residential care among those with the highest needs.

This is especially important as demographic ageing increases the prevalence of multimorbidity, frailty and cognitive impairment. Future demand is unlikely to consist only of more people requiring occasional home interventions. It will include larger numbers requiring complex and sustained coordination.

National and regional performance frameworks therefore need to connect coverage with measures such as timeliness, duration, professional mix, continuity, unmet need, avoidable hospital use, functional outcomes and the experience of people and carers.

The Quality Dashboard Builder offers organisations examining similar questions a practical way to bring capacity, quality and outcome indicators into one governance view. It does not measure Italian ADI performance directly, but it illustrates the broader principle that one successful access indicator should never obscure variation elsewhere in the pathway.

Regional variation becomes more important as national coverage rises

Italy’s decentralised health system means that national progress can coexist with meaningful territorial variation.

Regions entered the PNRR expansion from different starting points. They have different age structures, geography, workforce markets, existing community-health infrastructure and organisational models. Within Regions, metropolitan areas, provincial towns, islands and inner rural areas can also face different conditions.

This makes crude regional ranking unhelpful. Lower coverage may reflect weaker service capacity, but activity data need to be interpreted alongside population need, intensity and outcomes. High coverage can likewise conceal very light-touch interventions.

The stronger governance approach is to examine variation rather than merely label it.

Useful questions include whether people with comparable need can access comparable clinical support; whether rural travel reduces productive care time; whether some districts depend more heavily on family care because professional capacity is thin; and whether hospital discharge patterns expose gaps in particular territories.

Persistent variation becomes an equity issue when geography determines whether a person can convert a national healthcare guarantee into meaningful care.

This connects ADI with wider health inequalities and prevention. Territorial equity does not require every Region to organise identical teams. It requires sufficient national assurance that legitimate local adaptation does not become systematically unequal access.

Operational scenario: home care in an inner area depends on travel as well as staffing

An 86-year-old woman lives in a small inland community some distance from the nearest major health facility. She has heart failure, reduced mobility and recurring episodes of deterioration. Her daughter lives in another municipality and visits several times each week.

Clinical assessment indicates that the woman can remain at home if regular nursing oversight and appropriate medical follow-up are available.

The local challenge is not simply whether nurses exist within the regional workforce establishment. It is whether enough professional time can reach her home. Travel between dispersed communities reduces the number of visits each professional can make, and severe weather or transport disruption can make schedules less resilient.

The local service therefore combines planned face-to-face ADI visits with remote clinical contact where appropriate. The care plan identifies signs that require escalation and clarifies who responds if her condition changes. Her daughter is involved but is not treated as a substitute for professional monitoring.

Regional governance reviewing the service should not compare this territory with a dense city only through visits per employee. Geography changes the operating model and the cost of equivalent access.

The scenario demonstrates why workforce planning needs to account for deployment as well as headcount. A nominally adequate workforce can still produce inadequate capacity if distance, travel and skill distribution prevent professional time reaching the people who need it.

The home-care workforce determines whether expansion can be sustained

ADI depends on skilled professionals who can work effectively outside institutional settings. Nurses are particularly important, alongside doctors, rehabilitation professionals and other health and social-health roles according to the person’s assessed pathway.

Home care requires a distinctive form of professional autonomy. Staff work without the immediate infrastructure of a hospital ward. They need to recognise deterioration, communicate across services, manage time and travel, work safely in varied domestic environments and involve families without transferring inappropriate responsibility to them.

As ADI expands, workforce policy therefore needs to consider more than recruitment numbers. Geographic distribution, retention, professional development, workload, travel time, digital competence and multidisciplinary working all affect usable capacity.

There is also a productivity tension. Digital coordination and better scheduling can reduce wasted travel or administrative duplication, but home care cannot be industrialised indefinitely. Some activities require time in the person’s home, conversation, observation and relationship-based judgement.

The pressure becomes particularly acute where formal healthcare relies on a parallel layer of unpaid family care or privately employed domestic workers to sustain the person between professional visits.

Organisations modelling comparable pressures can use the Predictive Workforce Risk Module to structure analysis of vacancy, turnover and continuity risks. For ADI, the broader lesson is that national coverage commitments are credible only when workforce capacity can be sustained at territorial level.

ADI and family care are complementary, but the boundary needs to remain visible

Professional home care in Italy operates within a society where relatives continue to provide a substantial share of long-term support. Many households also employ a badante or other domestic care worker.

These arrangements can complement ADI effectively. A nurse may visit for clinical interventions while a family member supports meals and appointments and a paid care worker provides daily personal assistance.

The risk is that professional home care appears more comprehensive than it actually is because families quietly absorb the spaces between visits.

For example, an ADI plan may be clinically adequate on paper while remaining unsustainable because an elderly spouse is expected to supervise continuously, manage difficult transfers or coordinate multiple appointments.

Good assessment therefore needs to understand the household care ecology around the person:

• who is present between professional visits;
• what each person can realistically do;
• whether any domestic worker is involved and what their role is;
• whether the family understands escalation arrangements; and
• whether carer capacity is changing over time.

This does not mean converting relatives into unpaid members of the clinical workforce. It means recognising that the effectiveness of home care is partly shaped by what happens during the many hours when ADI professionals are not present.

The distinction protects both the person and their family. Home should be the first place of care because it can support autonomy and continuity, not because responsibility can be transferred invisibly from institutions to households.

Operational scenario: clinical care succeeds but the household arrangement begins to fail

A 76-year-old man with Parkinson’s disease receives ADI nursing and rehabilitation input. His wife provides most daily assistance and manages his medicines, meals and appointments. Their adult children live outside the Region.

For several months the arrangement appears stable. Clinical records show that scheduled professional visits are taking place and the man has avoided hospital admission.

During a routine visit, however, a nurse notices that his wife looks exhausted and has developed back pain. She admits that she is now helping him transfer several times each night and is afraid to leave him alone.

The issue is not a failure of the scheduled nursing intervention. It is a change in the capacity of the overall care arrangement.

The team therefore triggers review rather than waiting for a crisis. Rehabilitation reassesses mobility and equipment. The family doctor considers changes in the man’s condition. Municipal social assistance is explored for complementary support, and the family discusses whether additional paid help is required.

The governance lesson is significant. A narrow ADI dashboard might show full compliance with planned visits. A person-centred outcome view shows increasing risk.

This is why family partnership and carer support should be treated as part of sustainability, not simply as an expression of goodwill towards relatives.

Home healthcare and municipal social support need stronger interfaces

One of the enduring structural challenges in Italian long-term care is the boundary between healthcare responsibilities and social assistance.

ADI sits within the SSN. Social home support generally sits within municipal and territorial social-service arrangements. Their financing, eligibility processes, professional structures and information systems can therefore differ.

For people with limited needs, those differences may be manageable. For someone with advanced frailty or dementia, they can produce fragmentation.

A person may qualify for professional nursing but still need help getting out of bed. They may receive rehabilitation while their spouse struggles with meals and domestic tasks. A hospital may identify a clinically safe discharge while the social-support arrangement is not yet ready.

Integration consequently needs operational mechanisms: shared or coordinated assessment where appropriate, named contact points, timely information exchange, clear referral routes and escalation when one part of the package is missing.

The emerging national framework of Livelli Essenziali delle Prestazioni Sociali (LEPS) is relevant because stronger minimum social-service guarantees can help reduce the disconnect between nationally protected healthcare and more variable social support.

But formal standards alone cannot integrate a pathway. Local health and social structures need sufficient workforce, compatible processes and authority to resolve problems around individual people.

Digital infrastructure is becoming part of the home-care operating model

Italy’s PNRR does not treat home care, coordination and telemedicine as unrelated projects. The broader investment connects ADI expansion with Centrali Operative Territoriali and digital health infrastructure.

COT are designed to support coordination between professionals and settings, including territorial services, hospitals and other parts of the care network. Their value lies not in adding another organisational layer but in making transitions and information flow more manageable.

Telemedicine can complement home care for appropriate patients by supporting remote monitoring, specialist access and clinical contact. By June 2026, the national PNRR target of at least 300,000 people assisted through telemedicine tools had been reached.

Technology can therefore extend professional reach, but it should not be treated as a replacement for home visits where physical assessment, treatment or direct support is required.

Its strongest contribution is often coordination: allowing information to travel rather than requiring the person to travel unnecessarily.

This depends on interoperability and system integration. A remote observation is useful only if the relevant professional can see it, interpret it and act when thresholds are crossed.

Digital inclusion matters equally. Very old people, people with cognitive impairment and households without reliable connectivity may require assistance or alternative routes. Technology should extend the reach of ADI rather than creating a new eligibility divide based on digital confidence.

Operational scenario: telemonitoring strengthens rather than replaces professional care

A 79-year-old man with chronic heart failure has experienced repeated hospital admissions. Following assessment, his territorial care pathway combines ADI with remote monitoring appropriate to his clinical condition.

At home, agreed health measurements are transmitted through the digital pathway. The information does not simply accumulate in a record. The operating model specifies which team reviews it, what changes require clinical attention and when a face-to-face assessment is necessary.

Several weeks later, a pattern of deterioration appears before the man feels ill enough to call emergency services. The territorial team contacts him, reviews symptoms and arranges an appropriate clinical response. His treatment is reviewed without automatically defaulting to hospital admission.

The technology has not “replaced” a nurse or doctor. It has changed the timing of professional attention.

The scenario also exposes the governance requirements of digital home care. Data need to be reliable, responsibilities for monitoring must be explicit and alerts need an actionable response pathway. A device without response capacity simply produces information.

Organisations considering comparable digital models can use the Digital Transformation Readiness Assessment to examine strategy, workforce adoption and operational readiness. The relevant principle for Italy is that digital capability should be judged by whether it improves continuity and decision-making, not by the number of technologies deployed.

Quality needs to move beyond whether a visit occurred

ADI creates rich opportunities for quality measurement because care takes place over time and across professional boundaries. Yet home-care quality can easily become dominated by activity measures.

Activity remains important. Regions need to know how many people receive care, how quickly it starts and whether planned interventions occur. But mature assurance also asks what those interventions achieve.

For an older person receiving ADI, meaningful outcomes may include:

• remaining safely at home in accordance with their preferences;
• maintaining or recovering function;
• avoiding preventable hospital attendance or readmission;
• better symptom control and clinical stability;
• continuity between professionals and services;
• manageable demands on family carers; and
• a timely transition to different support when home care is no longer sufficient.

Not every adverse outcome is preventable. A person with progressive illness may require hospital admission despite excellent home care. Outcome measures therefore need clinical interpretation rather than simplistic performance attribution.

The stronger assurance model combines process, capacity, experience and outcomes. It also examines variation: a Region may achieve excellent aggregate coverage while particular districts have long waits or insufficient intensity.

This connects with wider quality data and performance measurement. National datasets such as SIAD provide important visibility, but governance needs to keep developing the information required to understand what home care means in practice.

Home should be a preferred care setting where it remains appropriate, not an absolute destination

The principle of casa come primo luogo di cura is powerful because many people prefer to remain in familiar surroundings and because appropriate home care can reduce unnecessary institutional use.

But home should not become an ideological endpoint.

Some people eventually need an intensity of nursing, supervision or specialist support that cannot be delivered safely or sustainably in their existing home. Others live in unsuitable housing or have no reliable support network. A family may reach the limits of what it can provide.

Person-centred care therefore requires honest review of whether home remains the right setting.

The objective is not to prevent residential care or hospital admission at all costs. It is to avoid unnecessary institutionalisation while ensuring timely transition when needs genuinely exceed available home capacity.

This is particularly important for people with advanced dementia, severe frailty, complex neurological conditions or palliative needs. Their preferences and rights remain central, but so do clinical safety and the wellbeing of those supporting them.

Strong ADI can delay or prevent some institutional transitions. It can also make necessary transitions better by ensuring that current needs, professional assessments and previous interventions are clearly understood.

The next phase is sustainability after PNRR expansion

The PNRR has provided Italy with an exceptional mechanism for accelerating territorial healthcare. ADI coverage has expanded, COT have been developed and telemedicine has moved further into the national operating model.

The long-term test begins when time-limited transformation funding no longer provides the same policy momentum.

Home care is recurrent, workforce-intensive activity. Nurses need salaries every year. Digital platforms require maintenance and cybersecurity. Vehicles, equipment and travel continue to cost money. Increasing numbers of older people will require support beyond the formal life of the PNRR.

Sustainability therefore requires Regions to embed expanded capacity within ordinary SSN planning rather than treating it as a temporary programme.

The central questions will include whether recurrent funding matches demand, whether professional recruitment can keep pace, whether expanded coverage is accompanied by sufficient intensity and whether territorial infrastructure changes hospital use in the way anticipated.

Demography increases the importance of this transition. Italy’s older population is growing while the working-age population is contracting. Home care therefore needs to become not only larger but more intelligently organised.

That means using professional time where it adds most value, strengthening prevention and rehabilitation, reducing avoidable administrative work, coordinating social support and using technology proportionately.

What Italy’s ADI experience offers internationally

Italy’s home-care expansion offers several lessons for countries attempting to shift care away from hospitals and institutions.

The first is that national ambition can accelerate change even in a decentralised system. Clear targets, dedicated investment and comparable data can create momentum while Regions retain responsibility for operational organisation.

The second is that coverage targets are useful but incomplete. Once access expands, policy needs to understand intensity, quality and outcomes. Otherwise systems risk celebrating the number of people touched by home care without knowing whether those with the greatest needs receive enough support.

Third, healthcare delivered at home cannot be separated indefinitely from social support. The institutional boundary may be necessary for funding and accountability, but the person experiences one life.

Fourth, workforce geography matters. Rural and inner-area access cannot be judged only against urban productivity assumptions.

Fifth, technology is most valuable when embedded within an operational response model. Remote monitoring, shared information and coordination infrastructure can extend reach, but none removes the need for professional judgement and human support.

Finally, “home first” works best as a person-centred principle rather than a cost-containment slogan. Other systems could adapt the principle without replicating Italy’s institutions: build enough capability around the person that home remains viable where it is safe, wanted and clinically appropriate.

Conclusion

Assistenza Domiciliare Integrata has become one of the most strategically important parts of Italy’s response to population ageing and chronic illness. It brings professional SSN care into the place where many people most want to remain and creates a practical bridge between hospitals, primary and territorial healthcare, rehabilitation and longer-term support.

Italy has already demonstrated that national investment and regional implementation can expand reach at scale. The achievement of the PNRR home-care target is significant. The next challenge is more demanding: ensuring that greater coverage produces sufficient intensity, continuity, equity and measurable benefit for people with increasingly complex needs.

That requires a wider operating model around ADI. Regional services need sustainable workforce capacity. Health and municipal social support need workable interfaces. Families must be partners without becoming invisible substitutes for formal provision. Digital systems need to connect information with real professional responses. Governance must examine territorial variation rather than relying on national averages.

The strongest future for Italian home care therefore lies not in maximising the number of visits or assuming that every person should remain at home indefinitely. It lies in making home a genuinely capable place of care: one supported by assessment, skilled professionals, coordinated services, technology where useful and timely alternatives when needs change. That is the point at which national reform becomes meaningful in the everyday lives of people and families.