Integrating Health and Social Care in Portugal: What the RNCCI Reveals About Joined-Up Care

A person leaving a Portuguese hospital after a stroke may be medically stable without being ready to resume their previous life. They may need rehabilitation, nursing, help with daily activities, family support and eventually community services. None of those needs fits neatly within a single institutional boundary. The practical question is therefore not simply which service is available, but whether health and social support can operate as one coherent pathway around the person.

Portugal’s Rede Nacional de Cuidados Continuados Integrados (RNCCI) was created precisely within this territory between acute healthcare and longer-term support. As explored across the Portugal Ageing, Long-Term Care & Community Support Knowledge Hub, the wider Portuguese system remains plural: the Serviço Nacional de Saúde (SNS), Social Security, social-sector organisations, private providers, municipalities and families all contribute different forms of support. The RNCCI does not dissolve those boundaries. It creates a structured mechanism for working across some of them.

That distinction matters. Integration is sometimes described as though organisational structures can simply be merged and fragmentation will disappear. Portugal’s experience shows something more operationally useful. Joined-up care depends on shared assessment, clear responsibility, appropriate referral, information transfer, aligned capacity, multidisciplinary practice and an agreed purpose for each stage of a pathway. Where any of those components weakens, formal integration can coexist with a fragmented experience for the person.

The RNCCI is an integration architecture, not a single service

The RNCCI was established in 2006 as a coordinated network spanning healthcare and social support for people experiencing dependency who require continuing care. Its development brought the health and social sectors into a more explicit shared framework, with responsibilities involving the Ministry of Health and the area of government responsible for labour, solidarity and social security.

The network includes different forms of inpatient and community-based response. Depending on assessed need, a person may require convalescence, medium-duration rehabilitation, longer-duration maintenance support, palliative responses or care delivered at home through an Equipa de Cuidados Continuados Integrados (ECCI).

These are not interchangeable placements.

The relevant response should reflect the person’s clinical condition, functional capacity, rehabilitation potential, dependency and social circumstances. This is why the RNCCI is best understood as a pathway architecture rather than simply a set of beds.

The network also operates through multiple provider types. SNS organisations, Instituições Particulares de Solidariedade Social (IPSS) and equivalent social-sector organisations, and private entities can all participate within the framework.

Portugal has therefore not created integration by making one organisation responsible for everything. It has created a governed network in which different organisations can contribute to an agreed pathway.

That makes organisational structure and accountability particularly important. A plural system can work coherently only when responsibility at each interface is sufficiently clear.

Integration begins with recognising that health and social needs interact

The conceptual strength of the RNCCI lies in recognising that dependency rarely has a purely medical or purely social explanation.

An older person recovering from pneumonia may need nursing and physiotherapy, but whether they can return home may also depend on whether they live alone, whether their home is accessible and whether someone can help with meals or personal care.

A person with advanced neurological disease may have stable clinical needs while requiring extensive assistance with daily life.

A stroke survivor may need rehabilitation while their family simultaneously needs preparation for a changed caring role.

These circumstances expose the limitations of organising services entirely around institutional categories.

Acute hospitals are designed principally to diagnose and treat illness. Social responses support everyday living and dependency. Primary healthcare provides continuing clinical support. Rehabilitation focuses on recovery or adaptation. Families often connect the spaces between them.

Integrated continuing care becomes necessary because the person experiences all these needs together.

The operational objective is therefore not integration for its own sake. It is continuity around a changing combination of health, functional and social needs.

Shared governance creates the framework, but integration is delivered locally

The RNCCI’s governance reflects its cross-sector purpose. National coordination establishes the overall framework, while regional and local structures support implementation, referral and network management.

In practice, however, integration happens much closer to the person.

Hospital professionals need to recognise continuing-care requirements before discharge. Primary healthcare teams need to understand what is happening at home. RNCCI teams need usable information about previous treatment and current goals. Social services may need to understand the person’s household and support network.

Each transition therefore depends on a chain of operational decisions.

This creates a governance challenge that applies to integrated systems internationally: responsibility can become most ambiguous precisely where organisations meet.

If a person deteriorates while waiting for a response, who notices?

If the person’s home situation changes after assessment, who updates the pathway?

If a family can no longer provide the support assumed within the plan, where is that information escalated?

If repeated delays occur between hospital discharge and community support, who sees the pattern rather than each individual case?

The Governance Maturity Assessment can help organisations examining comparable cross-boundary arrangements test whether responsibility, escalation and assurance remain visible. It is not an RNCCI governance instrument; its relevance lies in helping leaders examine whether organisational interfaces are governed as deliberately as internal operations.

Referral is one of the most important integration mechanisms

A joined-up system requires more than organisations agreeing to collaborate. It needs a practical method for moving people between them.

RNCCI referral provides that mechanism.

People can enter the network from hospital or community settings, with assessment considering the nature and level of continuing-care need. The pathway is therefore intended to match people with an appropriate response rather than leaving families to negotiate independently with multiple organisations.

This is a significant structural advantage.

Without an organised referral process, integration often depends on personal relationships, informal telephone calls or a family’s ability to navigate the system. That can produce inequality because people with greater knowledge or stronger advocacy networks are better able to secure coordination.

Formal referral reduces some of that dependence on individual navigation.

But the quality of referral matters as much as its existence.

Information needs to describe function, clinical needs, cognition, rehabilitation potential, social circumstances and the support available at home. A referral that describes diagnosis but not daily-life consequences gives the receiving service only part of the picture.

Likewise, assessment should remain current. An older person’s functional condition can change significantly during a prolonged hospital stay or while awaiting the next stage of care.

A stroke pathway shows what integration means in practice

Consider a 76-year-old woman living outside Braga who experiences a stroke. Before admission she lived with her husband, managed most daily activities independently and helped care for a grandchild. Following acute treatment she has reduced mobility, weakness on one side and difficulty completing personal care.

The hospital can no longer define success simply as clinical stabilisation.

Her next stage depends on rehabilitation potential, functional needs and the capacity of her husband to support her. The hospital team identifies a continuing-care requirement and the RNCCI pathway is considered.

If an appropriate rehabilitation response is available, the next objective is not merely occupancy of an RNCCI place. It is recovery against meaningful goals: transferring safely, walking further, managing personal activities and preparing for home.

Before discharge from that stage, the pathway changes again. Her home environment matters. So does access to primary healthcare, any required SAD support, family capacity and whether ECCI involvement is appropriate.

Good integration means that each service understands what the previous stage achieved and what the next stage is expected to do.

Poor integration would produce a sequence of individually competent services connected by weak transitions.

The distinction illustrates why transitions and hospital interfaces deserve as much attention as the services themselves.

Capacity determines whether an integrated pathway exists in reality

Integration can be well designed on paper while remaining constrained by capacity.

If the clinically appropriate RNCCI response has no available place, the hospital cannot simply create one. If community teams lack capacity, a person who could potentially recover at home may require another arrangement. If SAD provision cannot provide sufficient intensity, the formal pathway may still depend heavily on family care.

This means integration has a supply side.

Referral pathways, shared assessments and multidisciplinary teams cannot compensate indefinitely for insufficient service capacity.

The RNCCI has expanded over time, and investment under Portugal’s Plano de Recuperação e Resiliência has continued to increase and diversify continuing-care capacity. Yet demographic ageing means demand is also changing.

The relevant planning question is therefore not only how many places exist nationally. Decision-makers need to understand where capacity exists, what type it is, whether it has the required workforce and how quickly people can move through it.

An integrated system can become congested when one component expands without corresponding capacity elsewhere.

More hospital discharge activity can increase demand for rehabilitation. More rehabilitation can expose shortages in home support. Greater home-based care can reveal pressure on primary healthcare and family carers.

Integration therefore converts isolated capacity problems into visible system-flow problems.

Home-based integrated care changes the centre of gravity

The RNCCI is not only an institutional network. ECCI teams allow continuing care to be provided in the community for eligible people whose circumstances support home-based intervention.

This matters strategically because integration at home is different from integration inside an institution.

In an inpatient setting, many services can be organised around one location. At home, care is distributed across geography, organisations and time. A nurse may visit in the morning, a family member provide meals, a SAD worker assist later and primary healthcare remain responsible for other clinical needs.

The home itself becomes part of the pathway.

Portugal’s recent development of home-based continuing-care capacity, including expansion following ECCI pilots during 2025 and 2026, indicates an emerging policy direction towards strengthening care outside institutions. These developments should not be mistaken for uniform nationwide availability; implementation and capacity continue to vary.

The direction is nevertheless important.

Home-based integration can preserve routines and reduce unnecessary institutional transitions, but only where the practical support architecture is strong enough.

That requires home-support pathways to connect effectively with healthcare rather than operating alongside it.

The stronger model asks not “Which organisation owns this person?” but “What combination of support allows this person to achieve the agreed outcome safely at home?”

Health and social support operate through different funding logics

One of the deeper difficulties in integrated care is that organisational boundaries are reinforced by financial boundaries.

Portugal’s healthcare system is principally organised through the SNS and taxation, while social responses operate through Social Security arrangements, cooperation with the social and solidarity sector, household contributions and private purchasing. The RNCCI itself combines health and social dimensions within specific financing arrangements.

Integration therefore does not mean that all services become free at the point of use or that one funding mechanism replaces the others.

The distinction matters to families.

A person may move from an SNS hospital into a continuing-care pathway and later require a social response where household financial circumstances influence contribution. They may also purchase additional private support.

From the person’s perspective, the care need may feel continuous even though the financial rules change.

This is one reason integrated pathways need good communication.

Families need to understand what each service provides, what is publicly financed, where contributions may apply and what happens when one stage ends.

Financial ambiguity can otherwise become a form of fragmentation even where clinical coordination is strong.

Organisations examining complex multi-party pathways can use the Commissioner Evidence Builder to structure responsibilities, expected outcomes and evidence across contractual or partnership arrangements. Its terminology comes from a different system context, but the underlying discipline of making expectations explicit remains relevant.

Workforce integration is more difficult than organisational integration

Integrated care ultimately depends on people working differently.

Portugal’s continuing-care pathways involve doctors, nurses, physiotherapists, occupational therapists, social workers, psychologists, rehabilitation professionals, direct-care workers and other roles depending on the setting and person’s needs.

Multidisciplinary composition alone does not guarantee multidisciplinary practice.

Professionals need shared goals.

A physiotherapist may focus on mobility. A nurse may focus on clinical stability. A social professional may focus on household circumstances. A home-support worker may understand how the person actually manages daily routines.

Integration occurs when these perspectives inform one plan rather than remaining parallel assessments.

This is particularly important during transitions.

A rehabilitation professional may determine that someone can transfer with a particular technique, but the home-support worker who later assists them needs to understand it. A medication change made during admission needs to be understood after discharge. A family member expected to support mobility may require preparation.

Workforce shortages add another dimension.

Portugal has comparatively low formal long-term-care workforce density, and recruitment challenges affect both institutional and home-based services. Integration can therefore create additional coordination requirements for professionals who are already stretched.

That makes workforce resilience and continuity part of integration policy. Coordination should remove duplication and improve decisions rather than simply add meetings, forms and administrative work.

The family remains an important integration actor

Formal structures can obscure how much integration is performed by families.

Relatives frequently carry information between services, explain the person’s routines, organise appointments, collect medicines, provide transport and fill gaps between formal visits.

This contribution is valuable, but it should not be treated as unlimited capacity.

Consider an 83-year-old man in the Lisbon metropolitan area living with his 79-year-old wife. He is discharged after a period of rehabilitation with reduced mobility and several medication changes.

On paper, the pathway is coordinated. Primary healthcare will follow him, home support assists with personal care and his wife is present between visits.

Within two weeks, however, his wife is exhausted. She is helping him transfer at night, monitoring medication and cancelling her own appointments because she is afraid to leave him alone.

The formal services are functioning, yet the overall pathway is becoming unsustainable.

Good integration detects that change.

The response might involve reassessment, greater formal support, equipment, family guidance or a different care arrangement depending on need and eligibility. What matters is that the wife’s capacity is treated as a changing part of the pathway rather than a fixed resource.

This connects with family partnership and carer support. Integrated care cannot be considered successful if organisational coordination is achieved by transferring excessive responsibility to relatives.

Information needs to travel with the person

Integrated care is fundamentally information dependent.

Each organisation needs enough current information to make safe and proportionate decisions without forcing the person or family to reconstruct the entire history at every transition.

Portugal has invested substantially in digital health infrastructure, but integration across health and social support remains more complex than information exchange within the health system alone.

Different organisations may use different systems, collect different information and operate under different administrative arrangements.

The central challenge is therefore not simply digitisation.

It is interoperability.

Useful information should include more than diagnosis and medication. Functional ability, rehabilitation goals, communication needs, social circumstances, family involvement, risks and changes in daily living can all influence the next service.

At the same time, information sharing must remain proportionate and respect privacy.

Not every organisation requires every piece of data.

This makes interoperability and system integration both a technical and governance issue.

The Digital Transformation Readiness Assessment can help organisations examine whether digital capability, governance and workforce readiness are aligned before attempting more connected working. Technology can support integration only when responsibility for the information and the action it triggers remains clear.

Rural Portugal exposes the difference between pathway design and practical access

Integrated systems operate differently across geography.

In densely populated areas, hospitals, primary healthcare, rehabilitation, home-support providers and families may all be relatively close. In rural and interior areas, travel distances and workforce availability can reshape what integration is practically possible.

Consider an 81-year-old woman living in a village in Alentejo following a hip fracture. She has rehabilitation potential and strongly prefers to return home.

The clinical pathway supports that ambition.

But the nearest available services operate across a wide territory. Her daughter lives more than an hour away. The local SAD organisation can provide basic support but cannot easily add several short visits each day. Rehabilitation at home is constrained by travel time.

The question is no longer whether professionals agree on the desired outcome.

It is whether the local service ecosystem can deliver it.

A realistic plan may require combining rehabilitation, family input, home adaptation, scheduled social support and transport differently from an equivalent pathway in Lisbon or Porto.

This does not mean rural residents should receive lower expectations of independence. It means equity may require different operational models.

National integration policy therefore needs territorial intelligence. Average national capacity can conceal local areas where the pathway is structurally difficult to deliver.

Quality should follow the person across organisational boundaries

Traditional quality assurance often assesses individual organisations.

Integrated care requires an additional question: how well did the whole pathway work?

A hospital can provide excellent acute treatment. An RNCCI unit can deliver good rehabilitation. A home-support provider can meet its scheduled visits. Yet the person can still experience a poor outcome if the transitions between them are weak.

Pathway quality therefore needs evidence that crosses organisational boundaries.

Relevant indicators might include:

• whether referral information was complete and timely;
• how long people waited for the appropriate next stage;
• whether functional outcomes improved during rehabilitation;
• whether planned support was available when the person returned home;
• whether avoidable readmission or repeated escalation occurred;
• whether people and families understood the pathway and felt involved in decisions.

These measures reveal something that occupancy or activity figures cannot: whether integration produced continuity.

The Quality Dashboard Builder offers a practical way for organisations to structure a balanced view of activity, risk and outcomes. It does not replace Portuguese reporting requirements, but the underlying approach is useful where no single metric can describe integrated performance.

Integration should preserve rehabilitation rather than institutionalise dependency

One of the RNCCI’s most important strategic functions is to create space between acute treatment and permanent long-term support.

That space matters because dependency after illness is not always fixed.

A person who needs substantial assistance immediately after a stroke or fracture may regain significant function with rehabilitation. If the system moves too quickly from acute care into a static long-term arrangement, recovery potential can be underestimated.

Integrated care should therefore maintain a dynamic view of need.

Assessment asks what support is required now. Rehabilitation asks what the person may be able to do again. Social support asks what environment will sustain that improvement.

These perspectives need to remain connected.

Consider a 69-year-old man from Setúbal who develops severe deconditioning after a lengthy hospital admission. At discharge he needs help washing, dressing and walking.

An initial care plan based solely on current dependency could assume substantial continuing assistance.

A rehabilitation-led pathway instead sets functional goals and reviews support as his strength returns. Home assistance is initially intensive but reduces as he regains ability.

The outcome is not “less care” as an administrative objective. It is greater independence because support was designed around recovery.

This aligns with outcomes-based home support: the purpose of intervention should remain visible rather than allowing service activity to become the outcome itself.

Integration also needs to recognise when needs are becoming more complex

Not every pathway is about recovery.

Some people experience progressive neurological disease, advanced frailty, dementia or multiple chronic conditions that increase support requirements over time.

For them, integration means adapting coherently as needs change.

A person may initially manage with primary healthcare and limited SAD support. Later they may require more nursing, greater family involvement, equipment and closer monitoring. Eventually residential care or another continuing-care response may become appropriate.

The important issue is avoiding repeated crisis-driven transitions.

If each service sees only its own episode, escalation can appear sudden. If information is connected over time, the pattern may be visible earlier.

Repeated falls, increased missed medication, carer exhaustion and declining mobility are not separate administrative events. Together they may indicate that the existing support model is becoming unstable.

This is where quality data and performance intelligence can support more anticipatory care. Data are valuable when they help decision-makers recognise changing need rather than simply demonstrate that tasks occurred.

Integrated care should be judged partly by the experience of the person

Systems can become preoccupied with organisational integration while overlooking whether care feels integrated.

For the person, joined-up care has a more practical meaning.

Do they know what happens next?

Do they have to repeat the same information continually?

Do different professionals give conflicting advice?

Does support arrive when they return home?

Are they involved in decisions about where they receive care?

Does each transition preserve dignity and autonomy?

These questions matter because a technically coordinated pathway can still feel disempowering if the person becomes a passive object moved between services.

Integrated care should instead strengthen choice and involvement wherever meaningful options exist.

Choice is not unlimited. Capacity, eligibility and clinical need constrain what can be offered. But people can still be involved in goal setting, informed about alternatives and supported to understand why a particular pathway is recommended.

For people with cognitive or communication difficulties, involvement may require adapted communication and appropriate family or representative participation rather than simply recording that information was provided.

Persistent pathway problems require system-level learning

Integrated care becomes mature when recurring operational problems influence service design.

A delayed discharge can be treated as one difficult case.

Fifty similar delays indicate a capacity or pathway issue.

A single incomplete referral may be corrected locally. Repeated incomplete referrals suggest that the process, training or information system needs attention.

One family reaching exhaustion may require an individual reassessment. A pattern of carers becoming overwhelmed shortly after discharge may indicate that the pathway systematically overestimates informal capacity.

This distinction between case management and system learning is crucial.

Governance structures need visibility of recurring themes across organisations. Otherwise each part of the system can continue solving the same problem independently.

Useful learning questions include:

• Where do people wait longest within the pathway?
• Which transitions most frequently lead to readmission or escalation?
• Where does assessed need differ from the support eventually available?
• Which regions experience persistent gaps in particular RNCCI responses?
• How often does family capacity change the feasibility of discharge?
• Which information failures repeatedly affect continuity?

The objective is not to create another reporting layer. It is to convert operational evidence into decisions about workforce, capacity, referral and investment.

Portugal’s evolving home-care models may deepen integration further

Portugal’s recent policy experimentation suggests that integration is increasingly extending beyond the established RNCCI architecture.

The SAD+Saúde pilot launched in 2026 involves cooperation between Social Security and selected social and solidarity sector organisations to test more integrated health and social support at home. Separately, ECCI capacity has been expanding from earlier pilots across additional Unidades Locais de Saúde.

These developments are not yet equivalent to a universal integrated home-care model.

Their importance lies in the direction they indicate.

As more people live longer with multiple conditions, the boundary between a “health visit” and a “social care visit” can become operationally artificial. The worker providing personal support may identify deterioration. The nurse may recognise that a social problem is undermining treatment. The family may understand risks invisible during short professional contacts.

The future opportunity is not necessarily to merge every role.

It is to create reliable mechanisms through which different roles can act on shared information.

That requires clarity about professional responsibility, consent, escalation and what each service is funded and competent to provide.

Integration needs to become anticipatory, not merely transitional

The RNCCI demonstrates integration most visibly when people move between settings. Portugal’s next opportunity is to strengthen integration before transitions become necessary.

An ageing population will increasingly include people living for years with several chronic conditions, mild functional limitations and varying family support.

If health and social systems interact only after hospitalisation, integration begins too late.

Primary healthcare, SAD providers, municipalities, social organisations and families can collectively identify emerging vulnerability earlier.

A pattern of falls, weight loss, medication difficulty or reduced mobility can trigger review before crisis.

This links integration with prevention.

It also changes capacity planning. Earlier intervention may increase short-term community activity while reducing some downstream pressure.

The precise effects cannot be assumed, which is why scenario modelling is useful. The Digital Twin Scenario Modeller can help organisations explore how demand, capacity and service changes interact. It is not a Portuguese national planning system, but the principle of testing whole-pathway consequences is particularly relevant to integrated care.

What the RNCCI teaches other countries about integration

Portugal’s RNCCI is shaped by Portuguese institutions: the SNS, Social Security, a substantial social and solidarity sector, family caregiving and the country’s own administrative arrangements. Its structures cannot simply be transplanted into another health and long-term-care system.

Its experience nevertheless offers several important principles.

First, integration needs an operational architecture. Cooperation cannot depend solely on professional goodwill. Referral, assessment, responsibility and pathway rules matter.

Second, integration does not require one provider. Portugal demonstrates that public, social-sector and private organisations can participate in a common framework, although plural provision increases the importance of governance.

Third, capacity and integration are inseparable. A perfectly designed pathway cannot deliver timely care where the required response is unavailable.

Fourth, financing boundaries remain important even where services collaborate. Joined-up delivery needs to explain those boundaries rather than pretending they have disappeared.

Finally, integration should be measured through continuity and outcomes. Organisational activity alone cannot show whether the person experienced one coherent pathway.

The transferable lesson therefore lies less in reproducing the RNCCI itself and more in recognising integration as a discipline: organisations with different responsibilities need shared mechanisms for turning separate contributions into a continuous experience of care.

Conclusion

Portugal’s RNCCI shows both the value and the difficulty of integrating health and social care. Its significance lies not simply in the services contained within the network, but in the attempt to connect acute healthcare, rehabilitation, continuing care, social circumstances and community support around changing levels of dependency. That architecture provides Portugal with an important mechanism between hospital treatment and longer-term support.

Yet formal integration does not remove operational boundaries. Capacity varies, funding systems remain distinct, workforce pressures affect coordination, information does not always travel seamlessly and families continue to perform substantial connecting work. Regional geography further shapes what an integrated pathway can realistically deliver.

The stronger future direction is therefore deeper operational integration rather than structural integration alone. Referral information needs to support real decisions. Rehabilitation goals need to travel across settings. Home-based health and social responses need reliable interfaces. Family capacity needs to be assessed rather than assumed. Recurring delays and breakdowns need to become system intelligence rather than isolated cases.

Portugal’s experience demonstrates that joined-up care is ultimately judged at the point where institutions meet the person. If someone can move from illness through rehabilitation and into sustainable community life without repeatedly navigating organisational boundaries themselves, integration has practical meaning. As demographic ageing increases the complexity of long-term care, the RNCCI’s enduring strategic value will depend on how effectively Portugal continues turning a shared national architecture into continuous, locally deliverable and person-centred pathways.