Italy’s Long-Term Care Reform: From Fragmentation Towards a National Care System

An older person in Italy can still encounter several systems while trying to solve what, from their perspective, is one care problem. Healthcare may sit with the Servizio Sanitario Nazionale and regional services. Social assistance may depend on municipal and territorial arrangements. INPS administers major cash benefits. Family members and privately employed care workers may provide much of the practical support that connects everything together.

Italy’s current long-term care reform is an attempt to make that fragmented experience more coherent without abolishing the institutions that created it. Across the Italy Ageing, Long-Term Care & Community Support Knowledge Hub, this is the central reform question: can national coordination become strong enough to make different systems behave more like one care pathway while Regions, municipalities and national bodies retain their constitutional and operational responsibilities?

Law 33/2023 and Legislative Decree 29/2024 established the main architecture. The Sistema Nazionale per la Popolazione Anziana non Autosufficiente, or SNAA, is intended to provide permanent coordination across publicly funded measures for older people who are not self-sufficient. Unified multidimensional assessment is being introduced gradually. Punti Unici di Accesso are intended to simplify access. Personalised care planning, stronger home support, social LEPS and the experimental Prestazione Universale all form part of the broader direction.

Yet reform should not be confused with completed transformation. Several mechanisms remain in phased implementation, territorial practice still varies, and the distinction between statutory architecture and operational reality remains critical.

The reform does not create one new national care agency

The phrase “national care system” can be misleading if interpreted too literally.

Italy has not replaced regional healthcare, municipal social services, INPS and existing provider arrangements with one central institution controlling every long-term care service.

The SNAA is instead designed as a permanent organisational method for unified governance and coordinated delivery across measures that remain legally owned by the State, Regions and municipalities.

This is a significant distinction.

The reform recognises that long-term care fragmentation is partly structural. Healthcare and social assistance are governed through different legal, financial and administrative routes. Cash benefits have their own national mechanisms. Regional autonomy means delivery cannot simply be standardised through central operational command.

SNAA therefore seeks to create coordination above and across those boundaries.

Its architecture operates through several levels:

• national direction and coordination, including the interministerial CIPA;
• regional involvement through the relevant regional authorities, municipalities and territorial health organisations;
• local integration involving Ambiti Territoriali Sociali and health districts; and
• connections with existing social, health and social-health services rather than their wholesale replacement.

This makes organisational structure and accountability fundamental to implementation. A coordinating architecture only improves care if people know which part of the system remains responsible for which decision.

Law 33/2023 changed the direction of national ageing policy

Law 33/2023 created the legislative mandate for a broader reorganisation of policies for older people, with particular emphasis on non-self-sufficiency.

The reform extends beyond conventional long-term care. It addresses active ageing, prevention, autonomy, social inclusion, home support, integration and the rights of older people.

For non-self-sufficiency specifically, the law established several strategic principles that respond directly to historic fragmentation.

These include more integrated programming of health, social and assistance measures, stronger coordination between different levels of government, simplification of access, more coherent multidimensional assessment and greater emphasis on care at home.

The reform therefore shifts the conceptual centre of gravity.

Rather than treating healthcare, social services and cash benefits as independent programmes that happen to serve some of the same people, it seeks to organise them around the older person's combined needs.

That ambition is substantial because it requires institutions to change not simply what they provide but how they relate to one another.

The relevant principle of working across organisational boundaries is therefore embedded in the reform itself.

Legislative Decree 29/2024 translated the framework into operational architecture

Legislative Decree 29/2024 is the principal implementation decree for the older-person reform.

It sets out mechanisms covering active ageing, social inclusion, prevention, assessment, care planning, home support and services for older people who are not self-sufficient.

Its importance lies partly in moving the debate from strategic aspiration towards practical interfaces.

Who identifies need? Where does somebody enter the pathway? Who undertakes assessment? How should health and social professionals work together? How are care needs translated into a personalised plan? How should national benefits interact with local services?

These are operational questions.

The Decree strengthens the role of Punti Unici di Accesso, or PUA, as access and coordination points within local systems. It also develops the concept of unified multidimensional assessment through Unità di Valutazione Multidimensionale.

The reform architecture is therefore increasingly organised around a sequence:

entry and orientation, multidimensional assessment, identification of need, appropriate benefit and service decisions, personalised planning, delivery and review.

The potential improvement is obvious. Older people and families should have less need to navigate separate systems repeatedly.

The implementation risk is equally clear. If each stage still operates through disconnected information, waiting lists and organisational rules, a nominally unified pathway may remain fragmented in practice.

Unified assessment is one of the most important changes, but it is not yet fully national

The valutazione multidimensionale unificata is intended to create a more consistent approach to understanding non-self-sufficiency.

The assessment is designed around health, functional, social and broader bio-psycho-social needs rather than one narrow diagnosis or administrative category.

PUAs coordinate the assessment process locally, while multidisciplinary UVMs bring together relevant health and social professionals. The assessment is intended to inform access decisions and, where care and assistance needs are identified, the Piano Assistenziale Individualizzato.

This has the potential to reduce duplication between systems that historically assessed different aspects of the same person's circumstances.

But the rollout is deliberately gradual.

Changes introduced in 2025 provide for a 12-month experimental phase beginning on 1 January 2026, using a sample approach involving one province in each Region. Under the legislative timetable, the unified arrangements are intended to extend to the remainder of the country from 1 January 2027.

That distinction is critical in September 2026.

Unified multidimensional assessment is not yet a fully implemented national reality operating identically across every Italian territory. Existing regional and local assessment arrangements continue to matter outside and alongside the experimental implementation.

Presenting the future model as already universal would therefore overstate the reform.

Operational scenario: one assessment begins to replace repeated retelling

Carlo is 83 and lives in a province participating in the 2026 assessment experiment. He has heart failure, impaired mobility and increasing difficulty preparing food and managing personal routines. His daughter has previously had to explain his circumstances separately to health professionals, social services and benefit-related processes.

Under the emerging unified pathway, Carlo enters through the local PUA. His situation is considered across health and social dimensions rather than through several disconnected assessments.

The UVM identifies both clinical and functional needs. It also examines the support already being provided by his daughter and whether that arrangement is sustainable.

The assessment informs the subsequent care pathway and, where appropriate, a PAI.

The important outcome is not merely that one new form has replaced several old ones.

The reform succeeds only if information is accepted across relevant parts of the system, decisions are coordinated and Carlo does not have to restart the process every time responsibility moves between health, social or benefit structures.

The case therefore provides an implementation test: administrative simplification must be measured from the person's experience, not simply through the existence of a unified assessment instrument.

This connects directly with care planning and review. Assessment creates value only when it produces an actionable plan that can adapt as needs change.

The PAI is intended to connect assessment with actual support

The Piano Assistenziale Individualizzato is central to the reform because it translates assessed need into an organised care response.

The PAI should reflect the health and social needs identified through multidimensional assessment and involve the older person in planning.

That person-centred requirement is significant.

Long-term care reform can become dominated by architecture: committees, access points, professional teams, information systems and funding streams. The PAI is where those systems are supposed to become meaningful to the individual.

A useful plan needs to identify objectives, interventions, responsibilities and the contribution of different services. It also needs to recognise the role of family support without simply turning unpaid relatives into an assumed workforce.

The wider principle of person-centred planning for older people is particularly relevant here.

A technically integrated plan can still be poor if it prioritises service availability over the person's preferences, daily routines and goals.

The stronger opportunity lies in making the PAI a genuine cross-system operating plan rather than another document added to several existing care records.

The PUA could become the reform’s most important interface with families

Long-term care fragmentation is often experienced most acutely at the front door.

Families do not necessarily know whether a problem belongs to health services, municipal social assistance, disability benefits or a residential-care pathway. People can spend substantial time identifying the correct office before their needs are even assessed.

The reform strengthens Punti Unici di Accesso as local points for information, orientation, access and coordination.

Under the emerging framework, PUAs are intended to receive information and referrals, begin the process of taking an older person into care and activate unified multidimensional assessment where required.

The concept is closely connected with the wider territorial-health reform, including Case della Comunità.

Potentially, this creates a more intelligible system.

But a single front door cannot compensate for weak services behind it.

A PUA that efficiently identifies the need for social home support but faces a long waiting list has improved navigation without solving capacity. A PUA that generates an excellent PAI but cannot activate the required workforce has improved planning without changing the person's daily life.

For this reason, access reform and capacity reform need to develop together.

Organisations examining comparable restructuring can use the Governance Maturity Assessment to test whether roles, escalation and accountability remain clear as interfaces are redesigned. It is not an Italian statutory instrument, but it illustrates the wider need to match integrated access with integrated responsibility.

LEPS are intended to strengthen the social side of long-term care

One of the structural reasons for fragmentation in Italy is the difference between healthcare guarantees and social assistance.

The SSN operates through nationally defined Livelli Essenziali di Assistenza, or LEA. Social services have historically had a less uniform national floor.

Long-term care reform therefore needs stronger Livelli Essenziali delle Prestazioni Sociali, or LEPS, alongside the healthcare guarantees.

The objective is not to make health and social services institutionally identical. It is to create clearer minimum expectations for essential social support and connect them with healthcare more effectively.

This matters because non-self-sufficiency is rarely purely medical.

A person may have stable chronic disease while being unable to wash, dress, prepare meals or remain safely alone. Healthcare can manage the condition without solving the dependency.

Stronger social LEPS can therefore help close one of the system's most persistent gaps.

The challenge is implementation capacity.

An entitlement requires workforce, funding and local infrastructure. Municipalities and ATS begin from different positions. Some have established social-service networks; others operate with thinner staffing and provider capacity.

The reform therefore creates both a national standard-setting task and a territorial delivery task.

The 2025–2027 National Non-Self-Sufficiency Plan connects reform with funding

The Piano Nazionale per la Non Autosufficienza 2025–2027 became operational in 2026 and provides an important bridge between existing non-self-sufficiency policy and the emerging reform architecture.

The plan is backed by approximately €3 billion across the three-year period through the Fondo per le Non Autosufficienze.

The yearly allocation is approximately €982 million for 2025, €935 million for 2026 and €1.108 billion for 2027.

Within that framework, resources support services for people who are not self-sufficient, implementation of social LEPS, independent-living measures and staffing associated with PUA development.

This is important because structural reform without a financing mechanism would remain largely organisational.

Yet the Fondo per le Non Autosufficienze is not the whole Italian long-term care budget.

Healthcare expenditure, municipal social spending, national cash benefits, regional resources, household expenditure and unpaid family care remain substantial parts of the wider financing picture.

The reform therefore does not create one pooled national long-term care fund.

Financial fragmentation remains one of the hardest parts of integration.

National planning can align objectives while different institutions continue to control different resources. The operational test is whether those budgets can support one coherent plan around the person rather than creating several parallel packages based on organisational ownership.

Operational scenario: an integrated plan encounters three funding systems

Elena is 87 and lives in Lombardia. Following a stroke, she requires rehabilitation, assistance with personal care, medication support and substantial help during the day.

Her assessment produces a coherent view of need.

Delivering that plan is more complicated.

Part of her healthcare is financed through the SSN. Social support is organised through territorial and municipal arrangements. She receives Indennità di Accompagnamento, and her family considers using private resources to employ additional assistance.

From Elena's perspective, all four resources contribute to one objective: living safely at home.

From the system's perspective, they sit in different financial and administrative structures.

The reform challenge is therefore coordination without pretending those funding streams have already been merged.

The PAI can define how services fit together. The PUA can support navigation. Professionals can coordinate timing. But different eligibility rules, availability and administrative responsibilities still influence what is delivered.

For Elena, integration becomes real only if the resulting package functions across the day and week. A clinically excellent rehabilitation service does not compensate for an uncovered personal-care need every morning.

The scenario illustrates why decision-making and escalation matter within integrated systems. Where a planned element cannot be delivered, responsibility for resolving the gap needs to remain visible.

The Prestazione Universale is a targeted experiment, not a replacement for all existing support

The Prestazione Universale is among the most visible elements of the reform, but its scope needs careful interpretation.

The benefit is being tested from 1 January 2025 to 31 December 2026.

It is targeted at people aged at least 80 who meet stringent criteria including very severe care need, a socio-health ISEE not exceeding €6,000 and entitlement to Indennità di Accompagnamento.

For eligible people, the benefit combines the existing attendance-allowance component with an additional assistance allowance of approximately €850 per month.

The additional amount must be used within defined rules, including payment of appropriately contracted domestic care workers or purchase of qualifying non-residential social-care services.

This creates a stronger connection between cash support and actual home-based assistance than the traditional unrestricted Indennità di Accompagnamento.

It also creates a policy experiment around formalisation.

Requiring expenditure on legitimate care arrangements can encourage declared domestic employment and more visible service purchasing.

However, the benefit is deliberately narrow.

It should not be described as a universal long-term care allowance for all older Italians, nor as a permanent entitlement beyond the end of 2026. Its future depends on policy decisions informed by the experimental period.

The reform’s home-first direction depends on real service intensity

Italy's reforms consistently emphasise remaining at home, autonomy and reduced reliance on institutional care where appropriate.

This aligns with the preferences of many older people and with wider international trends towards community-based support.

But “home first” can mean two very different things.

In a strong model, sufficient professional, social and practical support allows somebody to remain at home with dignity and manageable risk.

In a weak model, the person remains at home because no alternative exists and the family absorbs the unmet need.

The distinction is service intensity.

Italy's substantial PNRR expansion of ADI has increased the number of older people reached through home healthcare. That achievement creates a stronger platform for reform.

Coverage alone is not enough.

People with significant dependency may require many hours of assistance beyond clinical visits. Social home support, rehabilitation, family respite and domestic care need to complement healthcare.

This places home-care demand, capacity and waiting lists at the centre of reform implementation.

A policy that prioritises home support needs evidence that the home-care system can deliver at the intensity required.

Workforce reform is the constraint beneath almost every structural reform

Italy can redesign assessment faster than it can create experienced professionals.

PUAs need adequately trained staff. UVMs require health and social professionals. ADI expansion requires nurses and other territorial workers. Municipal and ATS services need sufficient social-work capacity. Residential and home services continue to compete for workers.

The reform also depends indirectly on the domestic-care workforce.

The Prestazione Universale itself recognises this reality by permitting the additional allowance to support regularly employed domestic assistance.

Integration therefore creates additional workforce requirements rather than eliminating them.

Professionals need time to participate in multidisciplinary assessment and planning. Teams require skills in coordination and shared decision-making. Digital platforms require training. More sophisticated pathways can fail if administrative workload consumes the capacity intended for direct care.

The national framework needs to be tested against workforce planning at regional and local level.

The relevant question is not simply whether the reform identifies the right roles. It is whether those roles can be staffed sustainably in every territory.

Digital infrastructure is essential to making one assessment usable across several systems

Unified care depends heavily on information.

If an older person completes a multidimensional assessment but the resulting information cannot move reliably between the PUA, UVM, health services, social services and INPS where required, administrative duplication simply reappears.

The reform therefore anticipates digital information exchange as part of the assessment architecture.

This aligns with Italy's wider investment in the Fascicolo Sanitario Elettronico, telemedicine and digital territorial care.

But interoperability is not simply a technical challenge.

Systems need shared identifiers, agreed information standards, lawful access, reliable data quality and clarity about who can see and amend which information.

Social and health information also have different governance traditions and sensitivities.

The stronger model avoids both extremes: isolated records that prevent coordination and uncontrolled sharing that undermines privacy.

Organisations considering comparable transformation can use the Digital Transformation Readiness Assessment to test whether governance, workforce and infrastructure are sufficiently mature to support integrated workflows. The tool does not assess Italian compliance, but its underlying principle is directly relevant: digital systems need to support the operating model rather than merely replicate organisational silos electronically.

Operational scenario: the unified assessment works, but the information system does not

A province participating in the 2026 experiment successfully introduces the new assessment process.

Older people report positively on having fewer separate assessments. UVMs are identifying needs more comprehensively, and PAI documentation is clearer.

Within several months, however, operational problems emerge.

Social teams cannot consistently see updated health information. Some changes need to be entered into more than one system. INPS-related processes require information to move through specific channels, while local service organisations continue using separate software.

The assessment has become integrated faster than the information environment.

Leaders therefore distinguish reform compliance from reform maturity.

The province has implemented the required process, but the pathway still creates duplicate work and delays.

Governance begins tracking how often data are re-entered, how quickly relevant information becomes available and where professional teams rely on telephone calls or manual workarounds.

The response is not to abandon the unified model. It is to recognise interoperability as an implementation dependency.

This illustrates the wider relevance of interoperability and system integration: organisational integration becomes fragile if the information architecture remains fragmented.

Regional autonomy means national reform will still produce different local models

The SNAA is designed to strengthen national coherence, not eliminate regional autonomy.

Regions and Autonomous Provinces remain central to organising healthcare and social-health provision. Municipalities and ATS continue to operate within different local administrative and fiscal contexts.

This means reform will not create identical service models everywhere.

That can be appropriate.

Population density, provider markets, existing home-care structures and workforce supply differ substantially between Lombardia, Veneto, Toscana, Campania, Calabria, Sardinia and other territories.

The national system needs enough flexibility to accommodate those conditions.

The equity challenge is distinguishing legitimate adaptation from unacceptable variation.

One Region may achieve the same outcome through a different provider model from another. That is not necessarily a problem.

But if older people with comparable needs systematically receive lower service intensity, longer waits or weaker home support because of where they live, national coordination has not yet delivered substantive equality.

This is why reform needs national monitoring capable of comparing outcomes without demanding mechanical uniformity.

Governance needs to move from activity reporting towards implementation assurance

Large reforms can appear successful because structures have been created.

A PUA opens. A UVM meets. A new assessment tool is adopted. A regional programme is published. A funding allocation is distributed.

Each is relevant, but none proves that the person's experience has improved.

More mature governance asks what happens next.

Useful reform indicators could include:

• how long people wait between initial contact and assessment;
• whether repeated assessments genuinely decrease;
• how quickly a PAI becomes an active package of support;
• whether planned home-care interventions are actually available;
• whether families experience lower coordination burden;
• whether regional inequalities narrow; and
• whether outcomes such as independence, avoidable hospital use and carer sustainability improve.

The Quality Dashboard Builder can help organisations structure comparable outcome and implementation measures. It is not an official SNAA monitoring instrument, but the analytical principle is important: system reform should be evaluated through the difference it makes, not simply through implementation milestones.

This links directly with data quality and performance metrics. A nationally coordinated long-term care system requires information capable of revealing whether national policy is producing consistent operational progress.

The 2026 experiment should be treated as a learning system

The phased introduction of unified assessment creates something Italy has not always had during major social-care reforms: a structured opportunity to learn before universal implementation.

The 2026 provincial experiment can reveal practical issues around training, professional roles, assessment duration, interoperability, PUA capacity and harmonisation with disability-related assessment processes.

The value of the experiment depends on whether that learning changes the national rollout.

If all participating territories simply report completion, implementation risks becoming procedural.

A genuine learning model needs to identify:

where duplication persists, which cases create the greatest complexity, how long assessments take, what information professionals cannot access and whether PAI decisions translate into deliverable services.

Variation between pilot territories may be particularly valuable because it can reveal which implementation problems are local and which are structural.

The purpose of piloting is not to demonstrate that the legislation was correct. It is to improve the operating model before national scale.

Families will judge reform by whether coordination work actually falls

One of the most important reform outcomes may never appear clearly in conventional expenditure data.

Families currently perform substantial coordination work.

They telephone services, maintain medication lists, explain histories, arrange domestic workers, transport people to appointments, interpret eligibility rules and fill the gaps between different organisations.

Some of this involvement is valuable and chosen.

Some of it exists because the system is fragmented.

A successful reform should therefore reduce unnecessary family administration without excluding relatives from care where the older person wants their involvement.

The distinction is important.

Integration should not mean professionals taking over every decision from families. Nor should “family participation” become a way of transferring coordination back to households.

The person and their support network should experience a system that knows who is responsible, retains relevant information and can resolve routine interfaces without requiring relatives to act as permanent case managers.

The future of the Prestazione Universale will be an important reform decision

The end of 2026 will create a significant policy choice.

The Prestazione Universale is experimental and currently scheduled to end on 31 December 2026.

Its evaluation should therefore consider more than application numbers.

Did it increase formal home-based assistance? Did it support people with extremely high needs to remain at home? Did it improve employment formalisation among domestic care workers? Were the eligibility criteria so narrow that population impact remained limited? Did families find the expenditure and reporting requirements manageable?

The answers will matter if Italy considers extending, redesigning or replacing the mechanism.

The broader principle is important regardless of the eventual policy decision.

Cash support can increase choice, but connecting cash more explicitly to care services can create stronger accountability. At the same time, excessive restrictions can reduce flexibility and create administrative barriers.

The reform therefore needs to find a balance between autonomy, adequate assistance and assurance over the use of public resources.

Italy is moving towards integration, not yet operating a fully integrated national system

By September 2026, the direction of travel is substantially clearer than it was several years earlier.

Italy now has a statutory national coordination architecture through the SNAA. The 2025–2027 National Non-Self-Sufficiency Plan provides a current funding and planning framework. Unified assessment is being tested. PUAs have a stronger role. PAI development is more explicitly connected to multidimensional need. Home support, active ageing and prevention have gained greater policy prominence.

But important elements remain transitional.

The unified assessment model is not due to operate throughout the whole country until 2027 under the current timetable. The Prestazione Universale remains experimental. Workforce and provider capacity remain geographically uneven. Health and social funding have not been merged into one national care budget.

The reform should therefore be understood as the construction of a national coordination system rather than the completion of a single national long-term care service.

That distinction makes the progress no less important. It simply places the emphasis where it belongs: implementation.

What Italy’s reform offers international learning

Italy's institutional structure is distinctive, and countries with national long-term care insurance, more centralised social services or different constitutional arrangements cannot directly replicate SNAA.

The reform nevertheless offers several wider lessons.

First, fragmentation can sometimes be addressed through coordinated governance rather than institutional merger. Creating one organisation is not the only route to creating one pathway.

Second, unified assessment has little value unless it reduces duplication for the person and connects directly with resources.

Third, national minimum social standards become particularly important where health entitlements are more developed than social-care entitlements.

Fourth, home-first reform needs enough workforce and service intensity to avoid transferring responsibility invisibly to families.

Finally, phased implementation can be a strength if governments use pilots to redesign operational detail rather than simply validate predetermined models.

The transferable lesson lies less in Italy's specific institutions than in the reform logic: integration needs common direction, shared assessment, clear local responsibility, adequate capacity and evidence that the person experiences the system as more coherent.

Conclusion

Italy's long-term care reform represents a serious attempt to move beyond a historically fragmented combination of healthcare, social assistance, cash benefits and family support. Law 33/2023 and Legislative Decree 29/2024 have created a clearer national architecture through the SNAA, stronger access arrangements, unified multidimensional assessment, personalised planning and a greater emphasis on home-based support and social LEPS.

The reform is nevertheless still in transition. In September 2026, unified assessment remains within a phased experimental rollout before intended national extension in 2027. The Prestazione Universale remains a targeted two-year experiment. Regional capacity, workforce and service availability continue to vary, while financial responsibility remains divided across several public and private systems.

The decisive question is therefore no longer whether Italy has a reform framework. It is whether that framework can make different institutions operate coherently around the same person.

Success will be visible when families repeat themselves less, assessments lead more quickly to usable support, PAI decisions survive organisational boundaries and home-first policy is backed by sufficient care rather than unpaid household substitution. Italy does not need every Region to deliver identical services. It does need national ambition to translate into a dependable minimum experience of access, coordination, dignity and support.

If that implementation gap narrows, SNAA could become the mechanism through which Italy moves from several programmes serving older people towards something much closer to a genuine national long-term care system.