Integrating Health and Long-Term Care in Austria: Where Coordination Works and Where Gaps Remain

An older person with heart failure, diabetes, reduced mobility and early dementia does not experience Austria’s health system and long-term care system as separate policy domains. They experience one life. Their Hausarzt manages medical treatment, a mobile service may support personal care, a DGKP may provide nursing input, relatives organise appointments, Pflegegeld contributes towards care costs, and a hospital becomes involved when health deteriorates. The boundaries between those services matter only when they create delays, duplication, conflicting instructions or gaps in responsibility.

That interface is central to the Austria Ageing, Long-Term Care & Community Support Knowledge Hub. Austria has developed important mechanisms for coordination, including Zielsteuerung-Gesundheit, integrated health planning, expanding Primärversorgungseinheiten, Case- und Caremanagement, Community Nursing and increasingly digital information exchange. Yet health care and long-term care still operate through different funding logics and institutional structures.

The distinction is not inherently a flaw. Specialist systems need clear responsibilities. The challenge arises when those responsibilities fail to connect around people whose needs cross them continuously.

As Austria ages, that group will grow. More people will live with multimorbidity, frailty and dementia while remaining at home for longer. More Pflegeheim residents will require substantial medical and nursing input. More families will coordinate complex combinations of formal and informal support. Integration therefore needs to move beyond isolated cooperation projects towards a routine operational capability: knowing who is responsible, sharing relevant information, escalating changing need and planning services around the whole pathway rather than individual sectors.

Austria does not have one integrated health and long-term care system

The starting point is structural realism.

Austria’s healthcare system is shaped by federal legislation, the Länder, statutory social health insurance and healthcare providers. Hospitals, niedergelassene Ärztinnen und Ärzte, rehabilitation, medicines and other health services sit within financing and governance arrangements designed primarily around healthcare.

Long-term care is organised differently.

The federal Pflegegeld provides a cash benefit according to care dependency. The Länder and municipalities play major roles in organising and financing mobile, residential, day, short-term and other long-term care services. Families provide extensive unpaid support, while some households purchase additional private care or use 24-Stunden-Betreuung.

These arrangements create different gateways, funding responsibilities and administrative processes.

For a person with stable needs, those distinctions may cause limited difficulty. Complexity increases when several systems need to act at once.

A deterioration in mobility may require medical assessment, physiotherapy, equipment and additional personal support. Cognitive change may affect medication management and family capacity. A hospital admission may alter long-term care needs. A Pflegeheim resident may need specialist healthcare without requiring hospital transfer.

Integration therefore depends not on abolishing every institutional boundary, but on making those boundaries operationally permeable.

Zielsteuerung-Gesundheit creates a formal structure for cooperation within healthcare

Austria already has an important model for shared system governance through Zielsteuerung-Gesundheit.

Since 2013, Bund, Länder and Sozialversicherung have operated a partnership-based steering system for the structure, organisation and financing of healthcare. The current Zielsteuerungsvertrag covers 2024 to 2028 and continues this joint approach.

At federal level, the Bundesgesundheitsagentur and its governance structures bring together the federal government, Länder and social insurance. Corresponding Landesgesundheitsfonds and Landes-Zielsteuerungskommissionen operate at Land level.

The model matters because it recognises that healthcare cannot be planned effectively if hospitals, ambulatory care and social insurance act entirely independently.

Current policy priorities include strengthening ambulatory and primary care, improving integrated planning, expanding digital healthcare and directing people towards the appropriate level of care rather than defaulting unnecessarily to hospitals.

Yet Zielsteuerung-Gesundheit primarily governs healthcare. Long-term care has its own structures, financing and responsibilities.

The next integration challenge therefore lies partly at the edge of this framework: connecting healthcare planning more systematically with the services supporting daily living outside the conventional healthcare sector.

This is where organisational structure and accountability become practical rather than abstract questions. A sophisticated governance structure still needs to show how responsibility crosses into long-term care when the person’s needs do.

The principle of the “best point of service” has implications beyond healthcare

Austria’s current health reform direction emphasises care at the appropriate level, increasingly expressed through principles such as strengthening ambulatory provision and avoiding unnecessary reliance on hospital services.

For older people with long-term care needs, this cannot be achieved by healthcare reform alone.

A hospital emergency department may be clinically avoidable only if another service can respond. An older person with worsening oedema, confusion or reduced intake needs somebody in the community to recognise change, obtain clinical advice and organise the next response. A Pflegeheim needs accessible medical support if hospital transfer is not to become the default whenever a resident deteriorates.

The “best point of service” is therefore partly determined by long-term care capability.

A health system can strengthen primary care considerably and still experience avoidable hospital demand if home-care workers, Pflegeheime and families cannot access timely clinical support.

This makes long-term care capacity part of healthcare system performance even where the budgets remain separate.

Primärversorgungseinheiten create a stronger multidisciplinary platform

Austria’s expansion of Primärversorgungseinheiten, or PVEs, is an important development for integration.

PVEs bring general practitioners together with DGKP and, depending on the local model, other health and social professions such as physiotherapy, dietetics, social work or psychotherapy. They can operate as centres or networks and are intended to provide accessible, coordinated primary healthcare close to where people live.

By July 2025, Austria had reached 100 Primärversorgungseinheiten, demonstrating that the model has moved beyond a small pilot phase.

For older people with multimorbidity, the potential benefit is substantial.

Traditional fragmented appointments can require people and relatives to coordinate several professionals independently. A multidisciplinary primary-care model can make chronic disease management, nursing input, prevention and psychosocial support more coherent.

But PVEs are not long-term care agencies.

Their integration value depends on how effectively they connect with mobile Pflege- und Betreuungsdienste, Pflegeheime, Community Nursing, hospitals and family networks.

The stronger opportunity is therefore not merely more multidisciplinary primary care. It is primary care designed as an accessible clinical partner to the wider support system around the person.

Operational scenario: primary care becomes the clinical anchor for a complex home arrangement

An 81-year-old woman in Vienna lives alone with diabetes, chronic kidney disease and mobility problems. She receives Pflegegeld and support from a mobile service. Her daughter manages shopping and accompanies her to appointments.

Over several months, different problems emerge. The mobile-care worker notices increasing ankle swelling. Her daughter reports that dietary advice from one appointment appears to conflict with another. Medication has changed following a specialist consultation, but the woman is uncertain which tablets she should now be taking.

Nothing requires immediate emergency care, but the arrangement is becoming increasingly difficult to coordinate.

A multidisciplinary primary-care team provides a clearer clinical anchor. Her medication is reconciled, nursing observations are incorporated, and responsibility for follow-up is clarified. The mobile service knows which changes require escalation rather than relying on the daughter to interpret medical information.

The value is not that the PVE takes over the long-term care package. It remains a different service. Its role is to make the health component of that package more coherent and accessible.

If similar cases repeatedly reach the PVE with conflicting information or unclear responsibilities, the issue becomes a pathway question rather than an individual inconvenience.

Organisations examining comparable cross-service structures can use the Governance Maturity Assessment to test whether coordination, escalation and accountability remain clear when several organisations contribute to one person’s support.

Community Nursing provides a bridge between health, care and local communities

Austria’s Community Nursing programme is particularly relevant because its role sits deliberately across conventional organisational boundaries.

Community Nurses are qualified DGKP who provide advice, information, health promotion and coordination across regional health and social services. Their work can include identifying emerging need, supporting people and families to navigate services and linking different local actors.

The original Community Nursing programme was developed through a nationally supported pilot from 2021 to 2024. Its subsequent status is important.

Rather than ending automatically with the pilot funding period, Community Nursing was incorporated into the Pflegefonds as an eighth social-service category. This gives the Länder a statutory funding route through which Community Nursing can continue.

However, implementation is not uniform nationally. Länder determine how they continue and develop the model.

This is a good example of Austria’s wider integration architecture: national policy establishes a framework and funding possibility, while regional implementation shapes what people actually receive.

The model has particular potential for prevention because Community Nurses can become involved before somebody needs intensive formal care. This connects with prevention and early intervention by treating coordination as a means of maintaining independence rather than simply responding after breakdown.

Operational scenario: Community Nursing identifies risk before it becomes an admission

An older couple live in a rural municipality in Lower Austria. The husband provides most support to his wife, who has mobility difficulties and early cognitive impairment. Neither currently uses extensive formal long-term care.

During contact with a Community Nurse, it becomes clear that the husband has been increasingly exhausted and has postponed his own medical appointments. His wife has also fallen twice without serious injury.

No single event has yet triggered a major service response.

The Community Nurse can nevertheless see how the risks interact. The couple receive information about available support, the wife’s care needs are considered more systematically, and links are made with relevant local health and social services. Falls prevention, medication and the husband’s own health become part of the conversation.

The intervention does not necessarily result in a large immediate care package.

Its value lies in creating an earlier point of coordination.

If the husband later becomes ill, the couple are no longer entering the formal system for the first time during a crisis. Local services already have greater visibility of their circumstances.

The limitation is equally important: Community Nursing can coordinate available services, but it cannot compensate indefinitely where local service capacity is insufficient. Navigation and coordination are valuable only where there is something realistic to navigate towards.

Case- und Caremanagement addresses complexity inside long-term care

Austria’s long-term care architecture also recognises Case- und Caremanagement as a service function.

This is particularly important where somebody requires support from several organisations over time.

Case management focuses on the individual care situation: needs, goals, services and coordination. Care management addresses the wider organisation of supply and cooperation across the care system.

The terminology is less important than the operational purpose.

A person with increasing dependency should not have to reconstruct the entire system themselves every time a new need appears.

Effective coordination can clarify which service is addressing which need, identify duplication or gaps and provide a route for escalation where the existing arrangement no longer works.

This aligns with support planning and reviews, but adds a system dimension. The plan is not useful merely because each task is documented; it should make the relationship between services visible.

Home-based integration often depends on the observation skills of care workers

A major part of health and long-term care integration occurs far from formal coordination meetings.

It occurs when a Heimhilfe notices that somebody who normally prepares breakfast has stopped eating. It occurs when a DGKP identifies deterioration during Hauskrankenpflege. It occurs when a Betreuungskraft sees increased confusion after a medication change.

These observations matter because long-term care workers often see people more frequently than medical professionals do.

The question is whether the system can convert observation into appropriate clinical response.

This requires clear escalation routes, professional role boundaries and sufficient health-service accessibility.

A care worker should not be expected to diagnose heart failure. They should know that particular changes require escalation and who can provide the clinical judgement.

Similarly, delegating selected healthcare activities can support continuity where legally and professionally appropriate, but delegation should not blur accountability.

The principles of health integration and delegated tasks therefore apply much more broadly than disability care. Integration works when expertise reaches the point of care without making non-clinical workers responsible for decisions beyond their competence.

Pflegeheime need a strong healthcare interface because resident complexity is increasing

Residential long-term care illustrates the artificiality of separating health from care too rigidly.

A Pflegeheim resident may have dementia, diabetes, heart failure, chronic pain, mobility impairment and extensive medication requirements. Their home is a long-term care setting, but their healthcare needs remain continuous.

As people remain at home longer before entering residential care, Pflegeheime increasingly support residents with higher levels of dependency and multimorbidity.

The quality of healthcare access therefore matters directly to residential quality.

General practitioners, nursing professionals, pharmacies, therapists, specialists, hospitals and palliative services may all contribute. The Pflegeheim has to coordinate those relationships while maintaining the person’s daily routines and avoiding unnecessary disruption.

Hospital transfer should remain available where acute care is required. But if every clinical deterioration results in transfer because medical support cannot be accessed reliably within the home, the boundary between sectors is determining care more than the resident’s needs.

Operational scenario: avoiding an unnecessary hospital transfer requires clinical access

A resident in a Pflegeheim in Styria develops increasing confusion and reduced appetite. She has dementia, so behavioural change could easily be attributed to cognitive deterioration.

Staff who know her recognise that the change is unusual.

The relevant integration question is what happens next.

If accessible clinical assessment is unavailable, the safest option may become ambulance transfer to hospital. That may ultimately be necessary, but it should not be the only route to medical judgement.

Where the home has effective access to the resident’s Hausarzt or another appropriate medical service, nursing observations can inform timely assessment. A reversible problem such as infection, dehydration or medication-related difficulty may be identified and treated without an automatically disruptive hospital episode, provided the resident can safely remain in the Pflegeheim.

The outcome depends on several things working together: staff recognising change, an escalation process, medical availability, accurate medication information and sufficient nursing capability within the home.

This is why integration cannot be measured simply by counting multidisciplinary meetings. Its value is demonstrated when the right expertise becomes accessible at the point where a decision is required.

Families remain the most common informal integrators of fragmented systems

Where organisational integration is incomplete, relatives frequently bridge the gaps.

They carry medication lists between appointments, explain what the hospital said to the mobile service, telephone different providers, arrange transport, challenge conflicting advice and monitor whether planned services have actually started.

Families can perform this role extremely effectively because they often know the person better than any institution.

But a system should not depend upon it.

Some people have no available relatives. Others have family members who live far away, work full-time or have health problems of their own. Migrant families may face language or administrative barriers. The person may also prefer not to involve relatives in every aspect of care.

Good family partnership and carer support therefore uses family knowledge without converting relatives into unpaid coordinators responsible for making separate systems function.

Funding boundaries can create rational decisions that are irrational for the whole system

Austria’s health and long-term care sectors do not simply have different organisations; they also have different financing responsibilities.

Healthcare expenditure involves social health insurance, federal and Länder arrangements and hospital financing structures. Long-term care combines Pflegegeld, Pflegefonds funding, Länder and municipal expenditure, household contributions and private expenditure.

This can create incentives that make sense within individual budgets while producing higher costs elsewhere.

If sufficient mobile care is unavailable, a family may struggle until hospital admission becomes unavoidable. If a person remains in hospital because post-acute support cannot be organised, acute capacity absorbs the consequence of a long-term care constraint. If preventive home support is underdeveloped, higher-cost interventions may occur later.

No financing model eliminates these tensions completely.

The governance requirement is to make cross-sector effects visible enough that decisions are not evaluated solely within the budget where the immediate cost appears.

This does not mean every saving in healthcare should automatically be transferred to long-term care. Attribution is rarely that simple.

It does mean system planning should recognise that capacity in one sector changes demand in another.

The Pflegefonds strengthens long-term care capacity but does not merge it with healthcare

The Pflegefonds is an important federal instrument for supporting Länder and municipalities in securing and developing long-term care services.

For the 2024–2028 Finanzausgleich period, its role was substantially expanded, including support for workforce measures and the incorporation of Community Nursing.

This creates a stronger foundation for service development.

But the Pflegefonds remains part of the long-term care financing architecture. It does not create a single pooled health-and-care budget.

The distinction is useful because it prevents integration rhetoric from obscuring institutional reality.

Austria’s model is better described as increasingly coordinated parallel systems than as a fully integrated health and long-term care system.

The strategic question is whether those parallel structures can share enough planning, information and operational responsibility to produce continuity for people.

Digital integration is advancing, but information continuity remains broader than ELGA

Austria’s digital health infrastructure creates significant opportunities for stronger coordination.

ELGA provides a national electronic health record environment through which relevant health documents can be made available across authorised healthcare settings. Health reform for 2024–2028 also places further digital development and the interface with care services among its priorities.

This is important because fragmented information creates risk.

Medication changes, diagnoses, hospital treatment and clinical reports should not depend entirely on paper documents or families repeating information.

Yet integrating long-term care requires more than expanding a health record.

Long-term care generates different information: functional ability, daily routines, social circumstances, carer capacity, changes noticed during care visits and outcomes that may not belong naturally within conventional clinical documentation.

The goal should therefore be purposeful interoperability and system integration, not indiscriminate data sharing.

Authorised professionals need relevant information at the right time. Privacy and role-based access remain essential. A hospital does not require every detail of a person’s social-care record, just as every care worker does not require unrestricted access to every clinical document.

The Digital Transformation Readiness Assessment can help organisations examine whether technology strategy, information governance, workforce capability and digital infrastructure are aligned before introducing more complex forms of cross-service data exchange.

Operational scenario: digital information exists, but responsibility for acting on it is unclear

An older man in Salzburg is discharged after a cardiac admission. Updated clinical information is available digitally, and his medication has changed.

His daughter assumes the mobile nursing service can see everything the hospital has recorded. The mobile team assumes the Hausarzt will review the changes. The man himself has received discharge information but is confused by the new regimen.

The problem is not total absence of information.

It is uncertainty about who is expected to act.

A stronger transition clarifies responsibility explicitly. The relevant clinician reconciles medication, the mobile team knows which aspects affect its role, and the family understands whom to contact if discrepancies appear.

If digital integration merely makes information technically available without defining who reviews it, the system can create an illusion of coordination.

The scenario illustrates a wider principle: interoperability should connect information with workflow.

Someone needs to receive, interpret and respond.

Workforce integration matters as much as organisational integration

Austria cannot coordinate health and long-term care effectively without workers who understand one another’s roles.

GPs, DGKP, Pflegefachassistenz, Pflegeassistenz, Heimhilfe, Sozialbetreuung, therapists, pharmacists and Personenbetreuung contribute different capabilities.

Integration does not mean making those roles interchangeable.

It means developing enough shared understanding that each professional knows when another type of expertise is required.

Workforce shortages make this harder. Scarcity can encourage inappropriate substitution, delay professional review or concentrate specialist staff on tasks that other roles could safely undertake.

Better workforce planning therefore needs to consider the interface between sectors. Expanding home-based care, for example, changes demand for nursing, primary healthcare, therapy and coordination as well as personal support.

Technology may improve productivity, but it will also create new tasks: reviewing remote data, maintaining digital records and coordinating responses to alerts.

The future workforce question is consequently not just how many care workers Austria needs. It is what combination of roles allows more complex care to be delivered coherently outside hospital.

Regional variation is both a strength and a risk

Austria’s Länder have substantial responsibility for service organisation. This creates room for solutions that reflect different geographies and infrastructures.

Community Nursing is a clear example: the federal framework allows continuation, but Länder strategies differ.

The same principle applies more broadly.

Vienna does not need precisely the same integration model as a sparsely populated district in Tyrol. Rural areas may require stronger network models, remote specialist input and different travel arrangements. Urban systems can sustain denser specialist provision but may face greater organisational complexity.

Variation can therefore be appropriate.

The risk is variation in access to essential functions.

People should not need identical service names everywhere, but they do need workable routes to clinical assessment, long-term care advice, rehabilitation, carer support and escalation when needs change.

Governance should therefore compare outcomes and pathway performance, not simply structures.

Better evidence is needed about the interfaces themselves

Health services collect substantial data. Long-term care services also generate activity, workforce and quality information.

Integration requires another layer of evidence: what happens between services.

Useful indicators may include delayed transitions, repeated emergency use, unsuccessful referrals, time between identified need and service start, medication discrepancies, carer breakdown, duplicated assessment and avoidable changes in care setting.

None should become a simplistic performance target.

An emergency admission may be entirely appropriate. A delayed discharge may reflect careful planning rather than poor coordination. Measures need interpretation.

The value lies in patterns.

The Quality Dashboard Builder offers organisations examining similar pathways a practical way to combine activity, quality, workforce and outcome evidence rather than reviewing each dataset in isolation.

This is consistent with stronger quality monitoring systems: governance should be able to see not only whether individual services perform, but whether the pathway between them remains stable.

Austria’s current reforms create a stronger platform for coordination

The policy environment is moving in a direction that can support better integration.

The Zielsteuerungsvertrag 2024–2028 emphasises integrated healthcare planning, stronger ambulatory and primary care and further digitalisation. The Österreichischer Strukturplan Gesundheit provides a framework for integrated healthcare planning nationally and through Regionaler Strukturpläne Gesundheit. Community Nursing now has a continuing funding route through the Pflegefonds. Primärversorgungseinheiten have expanded substantially.

Further health-system financing reforms are also strengthening ambulatory care and patient pathways.

These developments should not be described as evidence that health and long-term care are now fully integrated.

They are better understood as infrastructure that makes stronger coordination possible.

The next step is implementation across the interfaces where people actually experience fragmentation.

The international lesson is coordination without pretending institutional differences have disappeared

Austria offers a useful international lesson precisely because its system remains institutionally plural.

It does not demonstrate that integration requires one organisation to control every budget and service.

Instead, it shows the value of governance structures that create shared objectives across otherwise separate actors, while also revealing the limits of coordination where long-term care remains outside key health-planning arrangements or where local service capacity is insufficient.

Other countries cannot simply reproduce Zielsteuerung-Gesundheit, the Pflegefonds or Austria’s social-insurance arrangements.

The transferable principle is more fundamental: organisations do not need to become identical in order to work around one person, but responsibility at the interface must be explicit.

Where that responsibility is unclear, families become coordinators, hospitals become fallback providers and service boundaries become visible as gaps in care.

The next phase should integrate pathways, not merely institutions

Austria’s strongest opportunity is to focus integration increasingly on specific population pathways.

Older people with multimorbidity, people with dementia, residents of Pflegeheime and people returning home after hospitalisation all have predictable points where health and long-term care intersect.

Those pathways can be examined systematically.

Who identifies deterioration? Who provides clinical advice? How quickly can community services respond? What information needs to move? Who coordinates where several organisations are involved? What happens outside normal working hours? Which outcomes indicate that the pathway is functioning?

Answering those questions often creates more practical integration than establishing another generic coordination body.

National and Länder governance can then use pathway evidence to decide where workforce, digital infrastructure or service capacity needs investment.

Conclusion

Austria’s health and long-term care systems are becoming more connected, but they remain structurally distinct. Zielsteuerung-Gesundheit provides a sophisticated framework for cooperation between Bund, Länder and Sozialversicherung within healthcare. Expanding Primärversorgungseinheiten, Community Nursing, Case- und Caremanagement, digital development and Pflegefonds investment all create stronger possibilities for coordinating medical treatment with everyday support.

The remaining challenge lies in the interfaces. A person with complex needs requires more than multiple competent services. Someone must recognise deterioration, make relevant information available, clarify responsibility and ensure that health interventions and long-term support do not proceed as separate plans. Families can contribute invaluable knowledge, but they should not be the mechanism that holds fragmented systems together.

Austria’s strongest forward direction is therefore pragmatic rather than institutionally grand. It does not require pretending that healthcare and long-term care have become one system. It requires making their boundaries work better: connecting primary care with home support, bringing clinical expertise closer to Pflegeheime, using Community Nursing and case management strategically, improving digital workflow and examining outcomes across complete pathways.

As demographic pressure increases, integration will be judged less by organisational diagrams than by lived continuity. The system will be working when people receive the right clinical and practical support without repeatedly encountering the gaps between who funds, governs or delivers each part of their care.