Italy’s Long-Term Care Reform: Turning National Ambition into Integrated Support for Older People

For an older person who needs help with washing, mobility, medication and meals, the distinction between healthcare, social assistance and family support is largely administrative. Their daily life is one continuous experience. Italy’s institutions, however, have historically divided responsibility across different systems, funding streams and levels of government. The result can be substantial support, but also complex pathways in which families themselves perform much of the work required to connect the parts.

Italy’s recent long-term care reform attempts to address that structural problem. Law No. 33 of 23 March 2023 and Legislative Decree No. 29 of 15 March 2024 establish a broad framework for policies supporting older people, including active ageing, prevention, assessment and assistance for people who are non-self-sufficient. Within the wider analysis developed through the Italy Ageing, Long-Term Care & Community Support Knowledge Hub, the reform matters because it seeks to change not merely individual services but the way responsibilities are connected around the person.

The ambition is significant. Yet legislation does not automatically produce integration. Italy remains a decentralised country in which the State, Regions, autonomous Provinces, municipalities, health authorities, social districts and different provider organisations hold distinct responsibilities. Existing benefits and services have their own histories, eligibility arrangements and funding constraints. Implementation therefore depends on whether a national reform architecture can create greater coherence without assuming that every territory begins with the same capacity.

The central operational question is consequently straightforward but demanding: can Italy turn a national commitment to integrated, person-centred long-term care into a pathway that an older person and their family actually experience as integrated?

Why Italy needed a long-term care reform rather than another isolated programme

Italy already had extensive arrangements supporting older people before Law No. 33/2023. The Servizio Sanitario Nazionale provides healthcare through a nationally defined but regionally organised system. Regions and local health organisations operate health and social-health services. Municipalities have responsibilities for social assistance. Residential and semi-residential services form another important component of provision. The national indennità di accompagnamento, or attendance allowance, provides a cash benefit to eligible people with severe disability and dependency without a means test.

Families then provide an enormous amount of unpaid assistance, often supplemented by privately employed personal assistants, including migrant badanti. The overall system therefore contains substantial resources and activity. Its longstanding weakness has been the difficulty of converting those separate components into a sufficiently coherent long-term care pathway.

An older person can simultaneously have a clinical condition managed through the health system, personal-care needs addressed through municipal or privately purchased assistance, a cash benefit administered nationally and a family member coordinating everyday support. Eligibility, assessment and access can differ between those components.

The distinction between organisational responsibility and the person’s actual life is precisely why service models and care pathways for older people matter. A system can contain individually valuable programmes while still requiring the individual or family to navigate the interfaces between them.

Law No. 33/2023 is important because it approaches ageing and non-self-sufficiency more systemically. It provides delegated authority for reform across policies for older people and establishes the basis for greater integration between social, health and social-health interventions rather than treating each programme as a separate policy problem.

Law No. 33/2023 establishes the strategic architecture

Law No. 33/2023 emerged within Italy’s wider reform commitments connected with the Piano Nazionale di Ripresa e Resilienza. Its scope extends beyond conventional long-term care. It addresses active ageing, social inclusion, prevention of frailty, assistance for older people who are non-self-sufficient and the coordination of policies affecting later life.

This breadth is significant because it recognises that long-term care does not begin at the point when severe dependency is formally established. The pathway into dependency may be shaped years earlier by health, housing, isolation, mobility, nutrition, access to prevention and support for family carers.

The reform therefore creates a continuum running from active ageing and prevention through increasing support needs to intensive long-term assistance. In principle, this enables policy to respond earlier rather than concentrating resources only after a person has reached a high threshold of dependency.

At national level, the law also establishes the Comitato Interministeriale per le Politiche in favore della Popolazione Anziana, known as CIPA. Its significance lies in bringing together policy areas that affect older people across ministerial boundaries. Long-term care is influenced by health and social policy, but also by housing, accessibility, employment, transport and broader social participation.

Cross-government governance cannot itself deliver a home-care visit or support a family carer. Its value lies in reducing the likelihood that national policies affecting the same population develop independently. The practical test is whether that coordination eventually changes priorities, resource allocation and implementation at territorial level.

The Sistema Nazionale per la Popolazione Anziana Non Autosufficiente changes the governance proposition

A central element of the reform is the Sistema Nazionale per la Popolazione Anziana Non Autosufficiente, or SNAA. Rather than being another provider organisation, SNAA is intended as a national framework through which policies and interventions for older people who are non-self-sufficient can be programmed and coordinated across the different institutional actors involved.

That distinction matters. Italy’s fragmentation cannot be solved simply by creating one additional service alongside the existing services. The governance problem sits between institutions. A national system therefore needs to connect the responsibilities of central government, Regions, autonomous Provinces, municipalities and the health and social structures operating locally.

The reform architecture is intended to support integrated planning and a more coherent relationship between health, social-health and social interventions. Organisations examining comparable multi-agency structures can use the Governance Maturity Assessment to structure questions about accountability, decision-making and assurance. It is not an Italian regulatory tool, but the underlying governance question is directly relevant: integration needs identifiable ownership rather than an assumption that coordination will occur because organisations share objectives.

For SNAA, success will therefore depend on whether responsibility becomes clearer at the interfaces. If an older person has health, functional and social needs, who ensures those needs become one coherent plan? If implementation differs persistently between territories, where does that variation become visible? If workforce capacity prevents an agreed service from being delivered, which part of the system owns the resulting risk?

These are operational questions rather than matters of organisational design alone.

Assessment is where reform becomes real for the individual

Few elements of long-term care reform matter more to an individual than assessment. Fragmented systems frequently require people to explain the same circumstances repeatedly to different organisations, with each assessment focused on the eligibility rules of a particular programme.

Italy’s reform seeks a more unified approach through a national multidimensional assessment framework for older people who are non-self-sufficient. The intention is important because long-term care needs rarely fit neatly within a single clinical diagnosis.

A credible multidimensional assessment needs to understand the relationship between health, functional capability, cognition, social circumstances, environment and available support. For an older person living alone, difficulty preparing food may have a different practical significance than it would for someone living with a capable partner. Similarly, mild cognitive impairment may create substantial risk where medication is complex or family support is distant.

This connects closely with assessment, review and changing needs. Assessment should establish more than eligibility at one moment. Long-term care is dynamic, and a pathway needs to respond when function improves, a carer becomes unavailable, dementia progresses or a hospital admission changes the level of support required.

Operational scenario: one person, several assessment routes

An 84-year-old man in Tuscany develops increasing difficulty with mobility following repeated falls. He also has diabetes and early cognitive impairment. His wife has been providing most everyday assistance but is becoming exhausted. Their son lives outside the Region.

Under a fragmented pathway, different parts of this situation can trigger separate processes. Healthcare professionals assess his clinical needs. Social services consider assistance available through the municipality or territorial arrangements. The family investigates national disability-related benefits. His wife’s ability to continue caring may receive attention only when the arrangement is already close to breakdown.

A genuinely integrated assessment starts with the person rather than the programme. His mobility, cognition, medication, ability to complete daily activities, home environment and family support are considered together. The resulting project should then translate that understanding into the appropriate mix of health, social-health and social interventions.

The practical test is not whether a multidimensional form has been completed. It is whether the assessment reduces duplication and produces decisions that the participating organisations recognise and act upon. The family should understand what has been agreed, which services are responsible, what remains privately or informally provided and how reassessment occurs if circumstances change.

If the wife is effectively indispensable to the plan, her capacity cannot remain invisible. Treating unpaid care as an unlimited background resource would undermine the purpose of multidimensional assessment.

This is where reform becomes tangible: one older person should increasingly be able to experience one coherent pathway even though several institutions remain involved behind it.

The individualised care project has to connect entitlement with delivery

Assessment creates value only when it changes what happens next. Italy’s reform places importance on developing an individualised assistance project that reflects assessed needs and coordinates the relevant interventions.

This introduces a fundamental person-centred principle: the objective is not to allocate isolated services but to organise support around the person’s circumstances, preferences and changing level of need.

That requires clarity about both professional and personal responsibility. An individualised project may draw on publicly funded healthcare, social-health services, municipal support, cash benefits, family care and privately arranged assistance. These components do not necessarily have the same legal basis or funding source.

The plan therefore needs to make the combination understandable without pretending that institutional boundaries have disappeared. Strong support planning and review depends on visible objectives, agreed responsibilities and a mechanism for responding when circumstances no longer match the original plan.

The operational risk is that personalisation becomes administrative language rather than practical control. A plan that records the person’s preferences but cannot mobilise sufficient support is not genuinely person-centred. Equally, a technically complete package that ignores whether the person wants to remain at home, how family relationships operate or what constitutes an acceptable daily life may coordinate services without coordinating them around meaningful outcomes.

Home-based support is central to reform, but integration determines its value

Italy’s reform direction strongly favours supporting older people in their own homes where this is appropriate and consistent with their wishes. This aligns with wider PNRR investment in territorial healthcare and the expansion of home healthcare for people aged over 65.

Yet “home care” can describe very different forms of support. Assistenza Domiciliare Integrata is principally a health and social-health intervention delivered through regional health arrangements. Municipal or territorial social assistance addresses different needs. Privately employed assistants may provide many hours of daily personal support that publicly organised services do not cover.

The reform challenge is therefore not simply to expand each component independently. It is to make the combination coherent.

An older person discharged after a stroke may require nursing, physiotherapy, personal assistance, meals, equipment and supervision. If each component has a different start date, assessment route and contact point, the family becomes the de facto care coordinator. The administrative system has moved the person home without necessarily creating a home-based pathway.

Stronger hospital discharge and reablement requires information about home circumstances to influence decisions before discharge, with community capacity considered as part of the pathway rather than discovered afterwards.

Operational scenario: discharge exposes the boundary between health and social support

A 79-year-old woman in Veneto is admitted to hospital after a fractured hip. Before admission she lived alone and received occasional help from her daughter, who works full-time. Following surgery and rehabilitation she is medically stable, but she cannot yet manage bathing, dressing, meal preparation or stairs without assistance.

The hospital pathway can identify the need for continued rehabilitation and health input. The more difficult question is how the everyday support required to make discharge safe will be assembled.

If health services, social services and the family work sequentially, discharge may be delayed while arrangements are negotiated. Alternatively, the woman may return home with a clinically appropriate rehabilitation plan but an inadequate response to daily living needs. Her daughter then fills the gap, reducing work or staying overnight until longer-term arrangements are established.

An integrated pathway considers these dependencies together. Functional assessment informs both rehabilitation and social-support planning. The home environment is assessed. Equipment is available when required. The daughter’s contribution is discussed rather than presumed. Responsibility for reviewing progress is clear because the package may need to change rapidly as the woman recovers.

Success is not demonstrated merely by discharge occurring. Relevant outcomes include whether she remains safely at home, regains function, avoids preventable readmission and receives the right level of support as her independence improves.

The scenario shows why long-term care reform is inseparable from health-system flow. Hospitals can transfer people physically, but effective transition requires the receiving community system to have both authority and capacity to respond.

Cash benefits remain important within a more service-oriented reform

Italy’s long-term care system has historically placed substantial weight on cash support, particularly the indennità di accompagnamento. The allowance is nationally administered and not means-tested, providing financial support to eligible people with severe disability who meet the relevant conditions.

Its strengths include national entitlement and flexibility. Households can use financial resources in ways that reflect their own circumstances. In practice, cash benefits may help families sustain home care or contribute towards the cost of privately employed assistance.

But cash and services perform different functions. A cash payment does not create a trained worker in an area experiencing labour shortages. It does not provide clinical governance, respite, rehabilitation or care coordination. Where households are expected to convert money into care themselves, differences in family knowledge, local markets and purchasing power can affect what support is actually obtained.

Legislative Decree No. 29/2024 introduced the Prestazione Universale as an experimental measure for 2025 and 2026 for a defined group of people aged 80 and over with very high care needs, subject to specified requirements including economic criteria. Its design combines the existing attendance allowance with an additional component intended to support the purchase of care services or appropriately contracted assistance.

The distinction between an experimental targeted measure and an established universal long-term care entitlement is important. It should not be interpreted as though every older person who is non-self-sufficient now receives a comprehensive new benefit. Eligibility remains defined and implementation needs to be judged on actual access and use.

Funding integration is harder than organisational integration

Long-term care reform inevitably raises a financing question. Italy’s existing arrangements draw resources from national social-security expenditure, the National Health Fund, dedicated national funds, regional budgets, municipal resources, household spending and unpaid family labour.

These resources are not interchangeable. Healthcare entitlements within the SSN have a different basis from means-tested municipal social assistance. National cash benefits operate differently again. Residential services can combine health-related public funding with social components and personal contributions according to applicable arrangements.

Creating a coordinated pathway does not automatically pool those budgets. This is one reason integration is difficult: organisations may agree about what a person needs while remaining responsible for different components of the cost.

Good governance therefore requires transparency about four questions:

• which elements of an individualised project are publicly funded and through which route;
• which services may require income- or means-related assessment or personal contribution;
• which needs are being met by family or privately purchased support; and
• whether the agreed package can actually be delivered within available territorial capacity.

The objective is not necessarily a single national funding pot. Italy’s constitutional and administrative structure makes responsibilities inherently distributed. The stronger requirement is that different funding responsibilities do not recreate fragmentation at the point of delivery.

Regions remain decisive to what national reform feels like locally

Italy’s Regions have substantial responsibility for organising healthcare and social-health services. They differ in demographic structure, fiscal capacity, provider infrastructure, workforce availability and established models of territorial care. Municipal social-service capacity also varies considerably.

National reform therefore enters a system with significant pre-existing territorial variation. This is not simply an implementation inconvenience. It determines what a new entitlement, assessment process or integrated plan can mean in practice.

A Region with established home-care infrastructure, strong territorial health services and effective relationships with municipalities may be able to incorporate new assessment and planning arrangements into an already mature pathway. Another territory may need to build workforce and organisational capacity at the same time as implementing the reform.

This creates a central accountability challenge. National policy needs enough flexibility for legitimate regional adaptation while retaining sufficient commonality to prevent a person’s access to coherent long-term care being determined excessively by postcode.

The relationship between national standards and regulation and oversight is therefore broader than inspection. It includes whether national institutions can see implementation differences, understand their causes and intervene through policy, funding or technical support when variation becomes persistent inequity.

For organisations translating strategy into measurable implementation, the Quality Dashboard Builder provides a practical way to structure balanced evidence across quality, workforce, experience and operational performance. It is not a substitute for Italian national or regional monitoring, but the principle is useful: implementation needs measures capable of showing whether formal reform is changing real service experience.

Municipalities are where social integration becomes operational

Municipalities and territorial social structures occupy a critical position because many determinants of whether an older person can remain independent sit outside healthcare. Personal assistance, social support, meals, transport, housing, community participation and help for families can all influence whether a clinical condition becomes a long-term care crisis.

This means integration cannot be achieved through the health system alone. Strengthening community healthcare without equivalent attention to social infrastructure can improve medical access while leaving the daily support gap largely unchanged.

The issue becomes particularly important in small or depopulating municipalities. A formal responsibility may exist without sufficient local workforce or provider capacity to deliver the same range of support available in a major urban area. Inter-municipal collaboration and territorial social organisation may therefore be essential for achieving viable scale.

National reform needs to recognise this difference between statutory responsibility and operational capability. A municipality cannot coordinate a service that does not exist locally. Nor can digital integration compensate fully for insufficient hands-on support.

Families need to become partners rather than invisible infrastructure

Italian long-term care has always depended heavily on family involvement. The reform’s stronger emphasis on integrated and personalised support creates an opportunity to make that contribution more visible.

This does not mean formalising every act of family care. Relationships should remain relationships. It does mean recognising that a care plan is unstable if it assumes relatives will deliver extensive support without establishing whether they are willing, able and likely to continue.

Family involvement needs to distinguish between the older person’s preferences and the needs of the carer. A person may want their daughter involved in decisions but not want her providing intimate personal care. A spouse may wish to continue caring but need respite to do so safely. A son living hundreds of kilometres away may coordinate appointments effectively while being unable to respond physically to an emergency.

This is why family partnership and carer support should be understood as a system-capacity issue as well as a relational one. Supporting carers can protect continuity, but formal services should not use family commitment as a reason to leave assessed needs unmet.

Operational scenario: the care plan works only because a daughter stops working

An 88-year-old woman in Campania has moderate dementia and increasing need for supervision. She receives a cash benefit and some formal assistance, while her daughter coordinates appointments, prepares meals and visits several times each day.

On paper, the arrangement appears stable. The woman remains at home, scheduled services are being delivered and there has been no recent hospital admission. The hidden indicator is the daughter’s employment. She has reduced her hours substantially because her mother cannot safely remain alone for long periods.

An integrated review needs to recognise that outcome. If the care plan is sustainable only because the daughter has absorbed the unmet hours, the apparent success of home care is partly a transfer of cost from the public system to the household.

The appropriate response may include greater formal assistance, a day service where locally available, respite, technology or different organisation of existing support. The mother’s wishes remain central, but so does an honest understanding of what makes those wishes achievable.

If the daughter later becomes ill or needs to return to full-time employment, the system should not have to rediscover the dependency from the beginning. Her role and the associated continuity risk should already be visible within review arrangements.

This illustrates one of the most important tests of Italy’s reform: whether integrated assessment can expose hidden dependency on unpaid care before that dependency becomes a crisis.

The workforce will determine the ceiling of reform

Italy can redesign assessment, governance and funding arrangements, but every service-intensive reform eventually encounters workforce capacity. Greater identification of unmet need can initially increase pressure because people who were previously supported informally or inconsistently become visible to formal systems.

Long-term care workforce planning therefore needs to span professional and non-professional roles. Nurses, physicians, rehabilitation professionals, social-health workers, social workers and personal assistants all contribute differently. The privately employed badante workforce is also too important to treat as peripheral to national planning.

Quality depends on more than the number of workers. Skill mix, training, supervision, employment conditions and continuity all affect outcomes. A home-care expansion built on unstable staffing can increase nominal capacity while creating repeated changes of worker and poor continuity for people with dementia or complex needs.

The relationship between reform and workforce skill mix and practice competence is consequently fundamental. New integrated pathways may also change roles. Staff need to communicate across organisational boundaries, use shared digital systems and recognise when a change in social circumstances requires reassessment rather than purely clinical intervention.

Organisations examining these pressures can use the Predictive Workforce Risk Module to structure analysis of vacancies, turnover and continuity. Its relevance here is methodological rather than regulatory: reform plans need to test whether workforce assumptions are credible before new demand is transferred into delivery systems.

Digital infrastructure can connect the pathway only if governance connects the data

Italy’s PNRR investments in digital health, telemedicine and territorial coordination create important infrastructure for a more integrated long-term care model. Digital systems can reduce repeated information gathering, support remote specialist input and improve continuity between settings.

But interoperability is not synonymous with integration. Two organisations may technically exchange information while still making decisions independently. Equally, a shared record is of limited value if responsibility for responding to the information remains unclear.

The stronger opportunity lies in combining interoperability and system integration with explicit workflow. If a home-care worker identifies rapid functional deterioration, the system should establish where that information goes, who reviews it and whether it triggers clinical assessment, social reassessment or both.

Digitalisation also raises questions of consent, privacy and inclusion. Older people should not lose access because they cannot navigate a digital interface. Family members may appropriately assist with technology, but access to information still requires clear authority and respect for the older person’s rights.

The Digital Transformation Readiness Assessment can help organisations examine the broader conditions needed for digital change, including governance, workforce adoption and resilience. Italy’s reform illustrates why this matters: technology creates integration only when operating models, people and accountability change alongside the platform.

Quality assurance needs to measure integration rather than individual services alone

Traditional quality systems often assess organisations or services separately. Integrated long-term care requires an additional level of assurance: whether the pathway between those services works.

An older person may receive clinically competent healthcare and good-quality personal assistance yet still experience poor overall care because information does not transfer, reviews are not coordinated or no organisation responds to a change in circumstances.

Useful implementation evidence therefore needs to include pathway measures as well as service measures. These might examine the time between assessment and support, repeated assessments, continuity after hospital discharge, frequency of unplanned escalation, reassessment following deterioration, carer experience and territorial differences in access.

Qualitative evidence matters too. Older people and families can identify fragmentation that administrative data misses. Being required to telephone several organisations repeatedly, not knowing who coordinates the plan or receiving contradictory advice are meaningful indicators of system design.

This creates a wider role for service-user feedback and co-production. Reform should not be judged only by whether institutions implement the required structures. It should also ask whether navigating long-term care becomes more understandable and whether people have greater influence over how support is organised.

Operational scenario: regional monitoring identifies a pathway problem rather than a provider problem

A Region reviewing long-term care data finds that one territory has an unusually high rate of hospital readmission among older people recently started on home-based support. Individual providers do not show an obvious pattern of poor clinical quality, and staffing indicators are broadly comparable with neighbouring areas.

A pathway review reveals that hospital discharge information frequently reaches community services late. Social-support assessments often begin only after the person has returned home, and weekend discharges create additional delays. Families are compensating during the first few days, but some people deteriorate before the complete package is established.

The important governance decision is not to treat the readmission rate automatically as a provider-performance problem. The evidence points towards an interface weakness involving several organisations.

The Region can therefore focus improvement on information transfer, pre-discharge assessment, weekend arrangements and responsibility during the transition period. Subsequent monitoring should test whether those changes alter both readmissions and family experience.

This is what integrated governance should make possible. Data identifies variation; analysis locates the problem at the correct level; responsibility is assigned across the pathway; and evidence then shows whether the intervention improved outcomes.

Without that system view, organisations can each demonstrate compliance with their own processes while the interface between them remains unsafe.

Rights and choice must remain visible within system integration

Integration is usually presented as an organisational good, but it is valuable only when it improves the person’s experience and outcomes. A highly coordinated system could still become paternalistic if efficiency takes precedence over autonomy.

Older people differ in how they want to live, who they want involved and what risks they consider acceptable. Remaining at home may be deeply important to one person and isolating to another. Residential care may be unwanted by some but provide security, social connection and appropriate support for others.

Assessment and planning therefore need to protect choice rather than use integration to direct everyone towards a preferred system outcome. This aligns with wider principles of co-production, choice and control.

Rights also include accessibility. Cognitive impairment, sensory loss, language, poverty, rural geography and digital exclusion can all affect a person’s ability to navigate new arrangements. Simplifying the formal pathway is valuable, but only if information and decision-making remain accessible to the people the reform is intended to support.

The implementation challenge is to make variation visible without standardising everything

Italy’s Regions are not identical, and successful reform should not require them to become so. Geography, population density, existing provider markets and organisational history justify different delivery models.

The governance challenge is instead to establish common expectations about what people should be able to rely upon while allowing local systems to determine how those expectations are delivered.

This requires national and regional monitoring capable of separating three forms of variation: intentional local adaptation, temporary implementation differences and persistent inequity. Treating all variation as failure would undermine decentralisation. Treating all variation as legitimate local choice would weaken national reform.

The evidence needs to support proportionate escalation. Where one territory repeatedly shows delayed assessment, inadequate home-care intensity or poor continuity, decision-makers should be able to determine whether the cause is funding, workforce, organisation, geography or another constraint.

That is a more mature model of accountability than simply checking whether a new procedure has been introduced.

What other countries can learn from Italy’s reform

Italy’s institutional model cannot be transferred directly to countries with different constitutional, insurance or local-government structures. SNAA, the SSN, regional responsibilities and national cash benefits are products of Italy’s own system.

The transferable lessons lie instead in the reform problem.

First, long-term care fragmentation is rarely solved by creating another service. Where responsibility is already distributed, the stronger intervention may be a governance architecture that connects existing actors around a common assessment and planning process.

Second, integration needs to encompass money as well as meetings. If organisations coordinate assessments while households still have to reconcile incompatible funding and eligibility arrangements themselves, much of the administrative burden remains with the person.

Third, family care should be visible within capacity planning. Systems that omit unpaid labour from their understanding of provision can underestimate both existing resources and existing risk.

Fourth, national consistency does not require identical local delivery. The important question is whether variation produces materially different rights, access or outcomes.

Finally, reform needs outcome evidence from the beginning. Structural change can consume considerable organisational effort while leaving the person’s experience largely unchanged. Measures of integration therefore need to examine continuity, access, independence and navigation rather than implementation activity alone.

The next test is whether reform survives the transition from legislation to routine practice

Italy has established a substantial policy framework at a moment when demographic change makes long-term care reform increasingly urgent. Law No. 33/2023 and Legislative Decree No. 29/2024 create a clearer national direction, but the difficult stage is now the translation of that direction into routine territorial practice.

Some changes will take time because they depend on organisational redesign, workforce development and alignment with existing regional systems. Other elements, including experimental measures, need evaluation before their longer-term role is clear. Funding constraints will continue to influence what can be implemented and at what pace.

The strongest implementation approach will therefore distinguish formal completion from operational maturity. Publishing guidance, establishing structures or adopting assessment instruments are necessary milestones. They are not the final outcome.

Reform becomes mature when an older person experiences fewer repeated assessments, when support arrives with less delay, when family contribution is recognised realistically, when hospital and community services operate as a pathway and when national and regional leaders can identify where those outcomes are not being achieved.

Conclusion

Italy’s long-term care reform addresses a fundamental mismatch: older people experience health, functional ability, family life and daily support as one reality, while the institutions responding to those needs have historically divided responsibility across multiple systems. Law No. 33/2023 and Legislative Decree No. 29/2024 provide an important framework for narrowing that gap through stronger national coordination, multidimensional assessment, individualised planning, prevention and greater integration of health, social-health and social support.

The strategic direction is significant, but implementation will determine its value. Regions begin from different positions. Municipal capacity varies. Workforce shortages cannot be solved through governance architecture alone. Cash benefits and services remain distinct, while families and privately employed assistants continue to carry a large share of everyday care. Integration therefore has to work with the reality of Italy’s mixed long-term care economy rather than assuming institutional boundaries can simply be removed.

The strongest forward direction is one in which national reform establishes meaningful common expectations while territorial systems retain the flexibility to organise delivery around local conditions. Assessment must lead to real support; digital connection must lead to accountable action; and quality assurance must reveal whether people experience continuity across organisational boundaries.

Italy’s reform will ultimately be judged less by the elegance of its institutional architecture than by something more practical: whether an older person and their family can move through long-term care with greater clarity, dignity, continuity and confidence that the different parts of the system are genuinely working together.