Italy’s PNRR and Long-Term Care: Investment, Reform and Service Transformation

Italy's Piano Nazionale di Ripresa e Resilienza has changed the scale and pace of investment in territorial healthcare. Community Houses have been developed, home healthcare has expanded, Centrali Operative Territoriali have created new coordination capacity, telemedicine has moved towards national infrastructure and Ospedali di Comunità are intended to strengthen the intermediate layer between hospital and home. Alongside these health investments, Mission 5 has supported social interventions designed to promote autonomy and reduce avoidable institutionalisation among vulnerable people.

For long-term care, however, the significance of the PNRR cannot be measured simply by counting facilities, technologies or people receiving at least one home healthcare intervention. The programme needs to be understood within the wider Italian system explored in the Italy Ageing, Long-Term Care & Community Support Knowledge Hub: a system in which the Servizio Sanitario Nazionale, Regions and Autonomous Provinces, municipalities, families, cash benefits, residential services and a substantial privately employed care workforce all contribute to support.

The central policy question is therefore what remains after PNRR implementation. Italy has demonstrated that national investment linked to defined milestones can accelerate change. The next challenge is harder: turning capital projects, expanded activity and digital platforms into durable operating models capable of supporting an ageing population over decades rather than funding cycles.

The PNRR is not a single long-term care programme

It is important to distinguish the PNRR's direct contribution to long-term care from the wider reform agenda surrounding it.

Mission 6, Salute, primarily concerns the health system. Its first component, M6C1, focuses on proximity networks, territorial facilities and telemedicine. These investments affect older and non-self-sufficient people substantially because they strengthen services that can prevent hospitalisation, support chronic conditions and enable more care to be delivered at home. But they do not constitute a comprehensive national social long-term care system.

Mission 5, particularly its social infrastructure component, addresses a different part of the landscape. Its interventions include support for vulnerable people, autonomy, housing-related solutions and measures intended to reduce institutionalisation. The reform commitments associated with the PNRR also helped drive the development of the national framework for older non-self-sufficient people that resulted in Law 33/2023 and Legislative Decree 29/2024.

These streams need to be read together without treating them as interchangeable.

Italy is simultaneously attempting to strengthen territorial healthcare, improve social support, reform governance for non-self-sufficiency and modernise digital infrastructure. The opportunity lies in their convergence around the person. The risk is that each investment succeeds against its own programme measures while citizens continue to experience separate systems.

This distinction is particularly relevant to organisational structure and accountability. Large transformation programmes require clarity not only about who delivers each project, but about who is responsible for ensuring that separate projects eventually create a coherent pathway.

Mission 6 has changed the infrastructure of territorial healthcare

The most visible long-term care implications sit within M6C1. Its architecture includes Community Houses, home healthcare, COT, telemedicine and Ospedali di Comunità.

The individual components perform different functions.

• Case della Comunità provide identifiable territorial locations intended to strengthen access, multidisciplinary care and local population management.
• Home healthcare brings professional SSN care into people's homes and has been expanded substantially through PNRR investment.
• Centrali Operative Territoriali coordinate care and transitions between professionals and settings.
• Telemedicine extends the potential for remote consultation, monitoring and support, particularly for people with chronic conditions.
• Ospedali di Comunità provide intermediate healthcare for people who do not require acute hospital treatment but cannot appropriately be supported at home at that point.

Together, these components represent an attempt to strengthen the space between general practice, the person's home and the acute hospital.

That is highly relevant to ageing. Many older people do not need a binary choice between independent living and hospital admission. Their needs fluctuate. They may require periods of nursing, rehabilitation, monitoring or more intensive clinical oversight followed by a return to lower-intensity support.

A stronger territorial network creates more possible responses to those changing needs.

But long-term care extends beyond them. Help with washing, dressing, meals, household tasks, supervision, companionship and daily living may be provided through municipal social services, family members or privately employed workers rather than Mission 6 structures. The PNRR can therefore strengthen the clinical architecture around ageing without automatically resolving every practical care need.

Home healthcare provides one of the clearest examples of rapid expansion

The PNRR objective of making the home a primary place of care has produced a substantial expansion of professional home healthcare for older people.

By 2025, national monitoring recorded 1,625,785 people aged over 65 receiving one or more interventions captured through the national home-care information system, equivalent to approximately 11.3% of the older population. This exceeded the PNRR target against which progress was being assessed.

That is a significant change in reach. It also illustrates why the next stage of performance management must move beyond coverage.

One person may need a limited episode of nursing following hospital treatment. Another may have advanced neurological disease requiring repeated multidisciplinary interventions. Both can appear in a coverage measure, while the resources and outcomes associated with their care differ substantially.

Italy therefore faces a transition from asking how many older people receive home healthcare towards asking whether the intensity, continuity and professional mix are appropriate to need.

This is closely connected to outcomes-based homecare. Activity remains necessary for accountability, particularly where PNRR targets are involved, but mature long-term care governance needs to understand what the activity achieves.

Relevant outcomes include maintaining function, preventing avoidable deterioration, supporting safe transitions, improving symptom management and enabling people to remain at home where this remains appropriate and consistent with their preferences.

Operational scenario: the target is achieved, but the care model still matters

Maria is 83 and lives with her husband in Veneto. Following a hospital admission for heart failure, she is referred for home healthcare. Nursing visits are arranged, her condition is monitored and the initial clinical episode is managed successfully.

From the perspective of PNRR coverage, Maria is one of the additional older people reached through expanded home care. From the perspective of long-term care, however, a more complicated picture emerges.

Her husband is 85 and has increasing mobility problems. Maria is finding bathing and meal preparation difficult. Their daughter lives 70 kilometres away and has begun travelling to the house several evenings each week. None of those pressures is resolved simply because the nursing component functions well.

A stronger pathway uses the clinical episode as an opportunity to identify the wider sustainability of the home arrangement. The relevant health professionals can recognise changing function and connect with appropriate territorial and social pathways. The family can be included without being assumed to have unlimited capacity.

The operational lesson is not that the PNRR home-care target is inadequate. Coverage was a necessary transformation objective. The lesson is that a programme-level measure and a person's outcome answer different questions.

As the investment period gives way to routine delivery, governance needs both. National authorities require evidence of programme implementation; Regions and local systems also need to know whether expanded home healthcare is creating viable care at home.

Community infrastructure changes where care can happen

PNRR investment in Case della Comunità and Ospedali di Comunità adds physical infrastructure to this wider model.

The minimum European PNRR target for Community Houses was revised from 1,350 to at least 1,038 following remodelling of the programme, partly in response to higher construction costs. The minimum target for Ospedali di Comunità was similarly revised from 400 to at least 307. Italy has sought to preserve the wider originally planned infrastructure through other funding sources where necessary.

The significance for long-term care lies in the functions these facilities can support rather than the construction programme itself.

Community Houses can provide a more visible territorial point for primary, nursing and multidisciplinary healthcare. Ospedali di Comunità can offer intermediate clinical support where a person is not sufficiently unwell for acute hospital treatment but cannot yet be supported appropriately at home.

This creates a potentially richer continuum.

An older person can move from hospital into lower-intensity intermediate care, return home with professional support and remain connected with territorial services rather than experiencing each transition as a separate episode.

The Digital Twin Scenario Modeller can help organisations examining comparable system redesigns test how capacity in one part of a pathway affects demand elsewhere. It is not an Italian planning instrument, but the principle is directly relevant: adding a new service layer changes flows only if capacity, referral criteria and surrounding services allow people to use it as intended.

Coordination is the less visible infrastructure

Buildings attract attention because their completion can be seen. Coordination infrastructure is less visible but may be equally important to long-term care outcomes.

The PNRR investment in Centrali Operative Territoriali is intended to strengthen coordination between the professionals and services involved when people move across settings. Following programme remodelling, the minimum European target was set at 480 COT, while Italy's wider planning has sought a more extensive territorial network.

COT matter because many failures in continuity occur at interfaces rather than inside individual services.

A hospital may complete clinically appropriate treatment. A home healthcare team may provide competent nursing. A general practitioner may know the person's history. A municipality may provide social support. Yet the overall pathway can still be weak if information, responsibility and timing do not connect.

Coordination becomes especially important for people with multiple conditions and changing dependency. Their care cannot be reduced to a single referral transaction.

The operational value of a COT therefore lies in whether it makes transitions more reliable: whether information reaches the next service, whether the receiving service is ready, whether changes in need are visible and whether unresolved problems are escalated.

This links directly with interoperability and system integration. Digital connectivity can support coordination, but organisational responsibilities still need to be clear. A shared system does not determine who acts on the information it contains.

Telemedicine has moved from aspiration towards national-scale implementation

Telemedicine is another area where the PNRR has accelerated implementation significantly.

The Mission 6 investment allocates substantial resources to telemedicine for people with chronic conditions and to the infrastructure needed to support national and regional services. The target required at least 300,000 people to receive care through telemedicine by June 2026. Monitoring subsequently recorded more than half a million people within the relevant reporting period, meaning the minimum target was exceeded.

This scale matters, but the same distinction between deployment and care-model maturity applies.

Telemonitoring can allow deterioration to be recognised earlier. Teleconsultation can reduce travel and extend specialist reach. Digital follow-up can make some pathways more convenient. For rural and inner areas, those benefits can be particularly valuable.

Technology can also create new operational responsibilities.

If an older person with heart failure sends daily measurements from home, someone needs to know which readings require review, who responds to an alert, what happens outside normal hours and how the response is recorded. If a person cannot operate the technology reliably, the pathway needs an alternative rather than treating non-use as non-compliance.

For this reason, digital inclusion is part of service quality rather than a separate technology issue.

Organisations considering similar transitions can use the Digital Transformation Readiness Assessment to examine whether governance, workforce, information and operating processes are ready to support technology-enabled care. The Italian context has its own national infrastructure and rules, but the implementation principle remains relevant.

Operational scenario: telemedicine changes the pathway rather than replacing it

Antonio is 79 and lives in a small town in Abruzzo. He has heart failure and chronic kidney disease and previously travelled regularly for specialist review. His daughter normally drives him, taking time away from work.

Through an expanded territorial pathway, some follow-up is provided remotely. Clinical measurements can be reviewed without Antonio travelling for every routine contact. When his weight and symptoms begin to change, the information prompts earlier clinical review.

The technology creates value because it changes the timing of intervention. It does not replace Antonio's general practitioner, nursing assessment, specialist expertise or the possibility of hospital care if his condition becomes acute.

It also changes the daughter's role. She may still support her father, but the service no longer assumes she can provide transport for every interaction.

The governance question is what happens when the digital pathway identifies risk. An alert without a response protocol merely transfers responsibility from the patient to an unattended dashboard. A mature model defines clinical thresholds, response times, accountability and escalation.

For Antonio, success is not measured by the fact that a device was issued. It is visible in earlier intervention, fewer unnecessary journeys, continuity of professional oversight and confidence that face-to-face care remains available when required.

Mission 5 connects the PNRR with social vulnerability and autonomy

Long-term care cannot be understood through Mission 6 alone.

Mission 5's social component has supported interventions for vulnerable people, including older non-self-sufficient people and people with disabilities. Its policy direction emphasises autonomy, personalised support, social inclusion and the prevention of unnecessary institutionalisation.

This is strategically important because remaining at home requires more than healthcare.

An older person may be clinically stable but unable to use the bathroom safely. Someone with cognitive impairment may need supervision and environmental support rather than a medical intervention. A family may need respite or practical assistance if a home arrangement is to remain sustainable.

The social dimension therefore determines whether the health ambition of "home as the first place of care" is workable in everyday life.

Mission 5 also intersects with the development of minimum social service guarantees and stronger territorial social structures. Italy's Ambiti Territoriali Sociali have an important role in implementing social interventions across municipalities and in building greater administrative and service capacity.

The broader direction supports independence and community inclusion. The strongest interpretation of ageing at home is not simply avoiding a residential placement. It is maintaining a viable life in which health, daily support, housing, relationships and participation are considered together.

The PNRR has also acted as a reform lever

Recovery funding has been accompanied by reform commitments. For long-term care, one of the most important was the development of a national framework for policies concerning older people and non-self-sufficiency.

Law 33/2023 and Legislative Decree 29/2024 seek stronger coordination through the Sistema Nazionale per la Popolazione Anziana non Autosufficiente and associated governance arrangements. They address issues including assessment, personalised planning, home support and coordination between health and social systems.

These reforms should not be presented as though Italy has already achieved a fully unified national long-term care system. Implementation develops through national, regional and territorial arrangements, and longstanding differences in capacity cannot be removed by legislation alone.

The significance of the PNRR is nevertheless institutional as well as financial. It has connected investment with a requirement to define reforms, standards, milestones and measurable implementation.

That creates a useful discipline. Capital expenditure becomes part of a wider theory of change rather than an isolated construction programme.

The challenge is ensuring that reform continues after the external milestone architecture becomes less dominant.

The Governance Maturity Assessment offers organisations considering comparable transformation a way to examine whether responsibilities, oversight and assurance are sufficiently developed to sustain change. It does not assess Italian statutory compliance; its relevance lies in testing whether governance has moved from project oversight towards enduring operational accountability.

Workforce capacity determines whether investment becomes service capacity

PNRR investment can finance infrastructure and support transformation, but a healthcare facility does not provide care without professionals and a home-care target cannot be sustained without a workforce capable of delivering it.

This is one of the most consequential long-term issues facing the programme.

Community Houses require multidisciplinary teams. Expanded home healthcare requires nurses, rehabilitation professionals, doctors and other staff. Telemedicine changes the skills and workflows expected of professionals. COT require people capable of coordinating increasingly complex pathways.

At the same time, the wider long-term care system relies heavily on social care workers, privately employed domestic care workers and family caregivers who sit outside much of the Mission 6 workforce architecture.

Investment therefore creates both capacity and demand for labour.

The question is not simply whether posts can be filled during implementation. Sustainable workforce planning needs to examine geographic distribution, professional roles, career development, retention, productivity and whether new services are drawing scarce professionals away from other essential functions.

This connects the PNRR with wider workforce planning. A transformation programme is only fully funded when the operating workforce required by its new infrastructure is financially and practically sustainable.

Operational scenario: a Community House opens but workforce capacity is constrained

A Community House in a southern Region opens following PNRR investment. The building is modern, digitally equipped and well located. Local expectations are high because residents have historically experienced difficulty accessing some territorial services.

The infrastructure milestone is achieved, but recruitment proves more difficult than expected. Nursing capacity is stretched and specialist sessions are available less frequently than planners initially envisaged. Existing professionals are asked to divide time between the new facility and established services.

The operational risk is that a visible new access point increases demand faster than the system can respond. Waiting develops, professionals experience additional pressure and some residents continue using hospital routes because these remain more predictable.

A mature response does not treat this solely as a recruitment problem. The Region and local health organisation examine demand, professional roles, opening patterns, remote specialist support, links with general practitioners and whether some functions can be delivered differently without weakening quality.

Performance reporting distinguishes the facility being operational from the service model operating at intended capacity.

That distinction matters nationally. If implementation reporting focuses only on infrastructure completion, workforce constraints can remain hidden until they appear indirectly through waiting, staff turnover or hospital demand.

Regional variation will shape the return on national investment

The PNRR is national, but healthcare organisation remains substantially regional. This means identical investment categories enter different starting conditions.

Regions vary in their existing territorial healthcare networks, workforce availability, provider landscape, digital maturity, geography and relationships between health and municipal services. A new Community House may therefore consolidate an already developed local network in one area while representing a much larger structural change elsewhere.

The same applies to home healthcare. Expanding the number of people reached is one objective; building sufficient intensity and multidisciplinary capability where the previous service base was thinner is another.

National funding can narrow infrastructure gaps, but infrastructure does not automatically equalise operational capacity.

This creates an important accountability question as PNRR implementation matures. Comparison needs to consider not only whether each Region delivered funded projects, but whether population access and outcomes are converging where national policy intends a common standard.

It also requires nuance. Rural Sardinia, central Rome and a metropolitan area in Lombardia cannot be expected to use identical operating models. Travel times, population density and labour markets differ. Equity should therefore be assessed through meaningful access and outcomes rather than superficial organisational uniformity.

For organisations examining this type of variation, the Quality Dashboard Builder provides a framework for bringing activity, capacity, quality and outcomes into one governance view. The specific indicators in Italy need to reflect national and regional information systems, but the analytical principle is transferable.

Capital delivery and service transformation need different evidence

The PNRR's milestone architecture has necessarily generated a strong implementation discipline. Projects require defined outputs, deadlines and evidence of completion.

That is appropriate for public investment. It is not sufficient for evaluating long-term care transformation.

Capital delivery asks whether the facility was completed and equipped. Programme delivery asks whether the target was reached. Service evaluation asks whether care improved.

Those questions overlap, but they should not be collapsed into one another.

As Italy moves beyond the intensive PNRR implementation period, a stronger evidence set will need to connect:

• infrastructure and operational readiness;
• workforce availability and service capacity;
• access, waiting and geographic equity;
• intensity and continuity of home healthcare;
• transitions between hospital, intermediate and home settings;
• patient and family experience; and
• outcomes such as function, avoidable deterioration and sustainable living at home.

This approach reflects wider quality data and performance measurement. The purpose of the next evidence phase is not to replace PNRR accountability, but to build on it.

A programme can legitimately be successful in delivering its agreed targets while still identifying further work required to achieve the full policy outcome. Recognising that distinction supports improvement rather than diminishing the value of what has been achieved.

Operational scenario: national success conceals different local outcomes

National reporting shows that home healthcare coverage for people over 65 has exceeded the PNRR target. At national level, the programme has therefore delivered an important expansion.

A regional analysis looks deeper.

One local health area has increased coverage substantially, but most people receive relatively limited episodes of care. Another reaches a smaller proportion of its older population but provides more intensive multidisciplinary support to people with high dependency. A third has expanded both coverage and intensity but is experiencing workforce instability that threatens continuity.

None of these patterns can be understood from a single national percentage.

The Region therefore combines coverage with measures of care intensity, professional mix, duration, outcomes and waiting. It also examines hospital activity and whether families report that formal services are actually reducing unsustainable care burden.

This does not mean abandoning national targets. It means using the achievement of those targets as the foundation for a more mature performance question.

The analysis may reveal that some territories need greater workforce capacity, while others need stronger referral pathways or better integration with municipal social support. Investment decisions can then respond to the reason for variation rather than simply allocating more of the same resource everywhere.

That is the point at which PNRR monitoring begins to evolve into long-term system governance.

The sustainability question begins when recovery funding ends

The PNRR was designed as an extraordinary recovery and resilience programme, not a permanent funding mechanism for ordinary service delivery.

This makes sustainability one of the defining questions for Italian long-term care after implementation.

New facilities require maintenance. Digital platforms require continuing development and cybersecurity. Home healthcare expansion requires recurring workforce expenditure. Community Houses and Ospedali di Comunità need staff and operating budgets. Telemedicine requires clinical time as well as technology.

The policy value of the PNRR will therefore depend partly on whether these costs are absorbed into sustainable national and regional arrangements.

This is not simply a financial question. Services need to become part of normal operating behaviour.

A COT that exists only because a transformation project required it has limited institutional resilience. A COT that becomes embedded in how professionals coordinate transitions represents structural change. The same distinction applies to multidisciplinary working, telemonitoring and proactive home care.

Sustainability therefore has three connected dimensions: recurring finance, workforce capacity and organisational adoption.

Italy's demographic direction makes this especially important. Demand associated with ageing and chronic disease will continue long after the PNRR timetable. Investment creates value when it changes the system's capacity to respond to that future demand.

The deeper opportunity is to connect health investment with long-term care reform

Italy's long-term care system has historically been distributed across healthcare, social assistance, national cash benefits, regional and municipal services, families and privately purchased care. The PNRR does not erase that structure.

Its greater strategic potential is to make some of the interfaces stronger.

Expanded home healthcare can connect more people with professional support. Community Houses can make territorial healthcare more visible. COT can improve coordination. Telemedicine can extend reach. Mission 5 interventions can strengthen autonomy and social support. Long-term care reform can provide a stronger framework for multidimensional assessment and personalised planning.

If those developments converge around people with complex needs, the combined effect can be greater than any individual investment.

If they remain separate, families may continue doing the integration themselves.

This is why family partnership and carer support remain important measures of transformation. An apparently integrated system that depends on an exhausted daughter carrying information between organisations is not integrated from the family's perspective.

The strongest future model would recognise family contribution while making formal coordination a system responsibility.

What Italy's PNRR experience offers internationally

The Italian experience is shaped by European recovery funding, the constitutional and administrative role of Regions, the structure of the SSN and Italy's particular long-term care arrangements. Other countries cannot reproduce the mechanism simply by adopting the same infrastructure labels.

The experience nevertheless offers several broader lessons.

Large-scale investment can accelerate change when funding is linked to clear milestones, implementation responsibilities and national monitoring. Infrastructure programmes can also create a rare opportunity to redesign services rather than merely expand existing ones.

But the distinction between project success and system success remains essential.

Counting facilities is appropriate when the task is delivering facilities. Counting people reached is appropriate when the task is expanding coverage. Neither measure alone establishes whether people experience sufficient, continuous and equitable care.

The transferable lesson therefore lies in sequencing. Transformation may begin with investment and measurable implementation, but it needs to progress towards workforce sustainability, operating maturity, outcomes and learning.

Another lesson concerns integration. Funding several connected components at the same time creates the possibility of system change, but integration still requires governance. Capital cannot substitute for accountability across organisational boundaries.

Finally, temporary transformation funding should be designed with the permanent operating model in view. The question "Who pays for this project?" eventually becomes "Who sustains this service, workforce and capability?" Systems that ask the second question early are more likely to preserve the value created by the first.

From recovery programme to enduring care infrastructure

By 2026, the PNRR has already produced measurable changes in Italy's territorial health landscape. Home healthcare coverage for older people has expanded beyond the original target. Telemedicine has reached large numbers of people. Community, coordination and intermediate-care infrastructure has been developed at a scale that would have been difficult to achieve through incremental change alone.

The next phase requires a different kind of leadership.

Programme management has concentrated on milestones, expenditure, delivery and certification. Long-term system stewardship must increasingly concentrate on capability, variation, outcomes and sustainability.

This means asking whether services have sufficient staff, whether new pathways reduce fragmentation, whether information follows people, whether rural populations have meaningful access and whether family care is becoming more sustainable rather than merely remaining invisible.

It also means being willing to adapt the model as evidence develops. Some investments will perform differently across territories. Technology will evolve. Workforce constraints will require role redesign. Demand may develop differently from forecasts.

A resilient system uses that variation as intelligence.

The transition from PNRR implementation to ordinary governance should therefore preserve one of the programme's strongest features: the expectation that ambition is translated into measurable delivery. The difference is that the measures now need to follow the person's experience as closely as they follow the investment.

Conclusion

Italy's PNRR has created an exceptional period of investment and reform across territorial healthcare, digital infrastructure and social support. For long-term care, its significance lies not in any single facility or target but in the possibility of creating a stronger continuum around ageing, chronic disease and non-self-sufficiency.

The programme has already demonstrated that nationally coordinated investment can accelerate home healthcare, telemedicine and territorial infrastructure. The enduring challenge is to ensure that these gains become operating capacity. Community Houses need multidisciplinary teams; digital platforms need responsive clinical pathways; COT need authority and relationships; expanded home healthcare needs sufficient intensity; and social support needs to connect with healthcare where people's lives cross institutional boundaries.

The decisive period therefore begins as extraordinary investment becomes ordinary service delivery. Italy's demographic pressures will persist beyond the recovery programme, making recurring finance, workforce sustainability, regional equity and outcome measurement central to the next phase.

The PNRR should ultimately be judged not only by whether Italy delivered what it funded, but by whether those investments changed what happens to an older person when needs begin to increase. If national reform, regional organisation and local delivery can convert new infrastructure into earlier support, stronger continuity and more sustainable life at home, the programme's legacy will extend well beyond its formal milestones.