Managing Complex Care Pathways in Italy: Shared Responsibilities, Escalation and Continuity

An older person in Italy may receive treatment in hospital, return home with nursing support, depend on a privately employed caregiver and require municipal assistance with everyday activities. If their condition deteriorates, the same person may need urgent reassessment, rehabilitation or temporary residential support. Each intervention may be appropriate individually, yet the overall pathway can become difficult to navigate when responsibilities, decisions and information are spread across different organisations.

Managing these complex pathways is an increasingly important challenge for Italy’s ageing population. The country’s Servizio Sanitario Nazionale (SSN), regional health organisations, municipalities and long-term care providers operate within different legal and financial arrangements. Their ability to coordinate effectively influences whether people experience timely intervention, avoidable disruption or continuity of support. These relationships form an important part of the wider system examined in the Italy Ageing, Long-Term Care & Community Support Knowledge Hub.

Law 33/2023 and Legislative Decree 29/2024 establish a reform direction towards more coordinated responses to older people’s needs. Meanwhile, Ministerial Decree 77/2022 provides a framework for strengthening territorial healthcare through health districts, community facilities and operational coordination. Implementation remains dependent on regional arrangements, workforce capacity and the maturity of local services.

The central operational question is not simply whether organisations cooperate. It is whether an individual can move between services without losing essential information, appropriate support or a clear route for resolving problems.

Complex care pathway governance must therefore connect professional responsibilities, service authorisation, escalation and individual outcomes across the full period of support.

What Makes a Care Pathway Complex in Italy?

Complexity is not determined solely by the number of diagnoses or the severity of an individual’s health condition. It also arises when different organisations must make related decisions, when family circumstances are changing or when the support required crosses separate financial and administrative systems.

An older person living with dementia, diabetes and reduced mobility may need specialist medical oversight, nursing, rehabilitation, assistance with personal care and support for a family caregiver. The clinical requirements may be relatively well understood, but arranging a coherent response can involve several distinct pathways.

Healthcare interventions may be provided through the regional SSN system, including territorial services organised by an Azienda Sanitaria Locale (ASL) or the equivalent regional organisation. Social assistance may involve the municipality or an associated Ambito Territoriale Sociale, depending on the territory.

Private providers, voluntary organisations and privately employed care workers may contribute further assistance. Family members frequently coordinate appointments, monitor changes and bridge gaps between formal services.

These arrangements can provide flexibility and preserve familiar relationships. They can also create uncertainty about who is responsible when circumstances change.

A pathway becomes particularly vulnerable when one organisation assumes that another has arranged an intervention, or when a professional recommendation is mistaken for an authorised service.

The principles of organisational responsibility and accountability are relevant because coordination requires an explicit understanding of decision-making authority, not merely agreement that cooperation is desirable.

Complexity should therefore be understood as a combination of individual need, service interdependence and the capacity of the system to respond coherently.

Italy’s Institutional Architecture and the Boundaries of Responsibility

Italy’s constitutional and administrative structure gives regions a central role in organising healthcare, within the national framework of essential healthcare services known as the Livelli Essenziali di Assistenza (LEA).

The Ministry of Health establishes national policy and standards within its responsibilities, while regional authorities organise services through their respective health systems.

Territorial healthcare is commonly delivered through ASL organisations, although names and organisational structures differ. Emilia-Romagna uses Aziende USL, Veneto has Aziende ULSS, and Lombardy operates a different arrangement involving Agenzie di Tutela della Salute (ATS) and Aziende Socio Sanitarie Territoriali (ASST).

These distinctions matter because an organisation’s title does not necessarily reveal whether it plans, purchases, coordinates or directly delivers a particular service.

Municipalities retain important responsibilities for social assistance, often working through intermunicipal arrangements. Their services may include support with daily living, social work and assistance intended to reduce isolation or maintain community participation.

The relationship between health and social responsibilities is especially significant in long-term care.

Assistenza Domiciliare Integrata (ADI) concerns integrated home healthcare within the relevant SSN arrangements. Municipal home assistance, often described as Servizio di Assistenza Domiciliare (SAD), addresses social and practical support under the applicable local rules.

Although both services may operate in the same household, they do not automatically share eligibility decisions, budgets or provider arrangements.

Similarly, residential provision through a Residenza Sanitaria Assistenziale (RSA) may involve healthcare and accommodation or social components governed by regional rules and individual contribution arrangements.

National cash benefits, including the Indennità di Accompagnamento administered by INPS, form another distinct element of the wider support environment.

Effective pathway governance must recognise these separate responsibilities while preventing them from becoming barriers to coordinated decisions.

The practical challenge is to ensure that people receive a coherent response without implying that one professional or organisation possesses authority over every part of the system.

From Assessment and Care Planning to Shared Pathway Management

Italy’s multidimensional assessment arrangements provide an important foundation for coordinating complex needs. A Unità di Valutazione Multidimensionale (UVM), or another appropriate multidisciplinary structure, may bring together clinical, functional and social perspectives.

The resulting Piano Assistenziale Individualizzato (PAI) can translate those findings into planned interventions and individual objectives.

However, assessment and planning do not by themselves guarantee that a pathway will remain coordinated.

Complex situations require continuing attention to the relationship between the person’s needs, the services available and the decisions being made by different organisations.

A PAI may establish that an individual requires nursing support, rehabilitation and assistance with daily activities. The pathway must then address whether those interventions have been authorised, when they will begin and how professionals will respond if the person’s circumstances change.

Responsibility for coordination varies across regions and service settings. Some pathways identify a professional reference point or case-management function, while others rely on multidisciplinary arrangements or organisational procedures.

There is no basis for assuming that one nationally uniform care coordinator has authority over all Italian health and social services.

Nevertheless, a complex pathway should make several matters clear:

• Which organisation is responsible for each authorised intervention.
• Who receives information about significant changes in the person’s circumstances.
• Which professional or service can initiate reassessment.
• How urgent clinical concerns are distinguished from social-service difficulties.
• Who communicates decisions to the person and their chosen representatives.
• How unresolved coordination problems reach the appropriate organisational level.

These arrangements should be proportionate to the complexity of the individual’s circumstances.

A person receiving a single stable intervention may need relatively straightforward coordination. Someone with progressive cognitive impairment, multiple conditions and a fragile home support arrangement may require more frequent communication and clearly defined contingency arrangements.

The strongest approach combines individualised planning with active oversight of the pathway itself.

Operational Scenario: Coordinating a Complex Hospital Discharge in Veneto

Consider an illustrative case involving an 82-year-old man in Veneto who is preparing to leave hospital following treatment for pneumonia and complications associated with heart failure.

Before admission, he lived with his wife, who assisted with medication reminders, meals and household activities. His mobility has deteriorated during hospitalisation, and his wife is increasingly concerned about managing his care at home.

The hospital team identifies ongoing nursing and rehabilitation needs. The relevant Azienda ULSS territorial services must consider how healthcare support can be organised following discharge.

A Centrale Operativa Territoriale (COT), where operational within the local arrangements, can support communication between hospital and territorial services. However, its coordinating function does not mean that it independently authorises every health and social intervention.

Municipal social services also need to consider whether practical assistance is appropriate and available.

The discharge pathway therefore involves several related decisions rather than one single approval.

The man wishes to return home, but his wife explains that she cannot safely assist him with transfers without additional support.

The team considers rehabilitation, appropriate equipment and the practical arrangements needed for the initial period at home.

Healthcare interventions are organised through the relevant territorial pathway, while any municipal assistance follows its separate assessment and authorisation arrangements.

During the first week, the wife reports increasing breathlessness and difficulty attending follow-up appointments.

The clinical concern requires timely contact with the appropriate healthcare professionals. The transport difficulty may require a different response involving family, territorial services or community support.

The important governance distinction is that both problems affect continuity, but they do not have identical escalation routes.

At review, the team considers whether the original arrangements remain appropriate and whether coordination between hospital discharge and home support needs improvement.

The scenario demonstrates how effective pathway management depends on clear responsibilities, realistic preparation and the ability to respond after discharge rather than treating discharge itself as the endpoint.

Escalation: Matching the Response to the Nature of the Risk

Escalation is a central feature of complex pathway governance because different problems require different professional and organisational responses.

A sudden deterioration in breathing, consciousness or another serious clinical condition requires an appropriate urgent healthcare response. A missed municipal assistance visit, an unresolved service eligibility decision or a disagreement about residential placement involves different responsibilities.

These issues may interact, but treating them as interchangeable can delay action.

Clinical professionals retain responsibility for decisions within their competence. Social workers and municipal services address matters within their respective responsibilities. Providers must respond appropriately to incidents and concerns arising during their own delivery of care.

Where a problem crosses organisational boundaries, the pathway needs an agreed mechanism for communication and resolution.

The relevant arrangements may include contact with the person’s Medico di Medicina Generale (MMG), territorial nursing services, specialist teams, social services or the appropriate emergency healthcare system.

Escalation should not depend entirely on a family member repeatedly contacting different organisations to establish who can help.

The wider principles of decision-making and escalation are useful because they distinguish immediate operational responses from issues requiring management or system-level attention.

For organisations reviewing these arrangements, the Governance Maturity Assessment can provide a general framework for examining clarity of responsibility and oversight. It is not an Italian regulatory instrument and does not replace locally applicable procedures.

The central test is whether a person experiencing a significant change can obtain an appropriate response without avoidable uncertainty about responsibility.

Funding, Authorisation and the Risk of Unresolved Service Gaps

Financial and administrative boundaries are among the most persistent influences on continuity within Italian complex care pathways.

Healthcare services operate within the SSN and regional arrangements, while municipal social assistance is governed by separate responsibilities, resources and eligibility rules.

Some services may involve personal contributions, including arrangements influenced by the Indicatore della Situazione Economica Equivalente (ISEE), where applicable.

The distinction between professional recommendation and formal authorisation is therefore essential.

A multidisciplinary assessment may identify a need for increased practical assistance, but the relevant municipality may need to consider eligibility and service availability before assistance can begin.

Similarly, a recommendation for residential care does not automatically resolve placement availability, the applicable healthcare component or any accommodation and social charges.

These boundaries should be explained to the person and family in clear language.

Otherwise, a plan may appear comprehensive while important interventions remain unavailable or unconfirmed.

From a governance perspective, unresolved service gaps should remain visible.

Organisations need to distinguish between needs that have been assessed, services that have been approved and interventions actually delivered.

This distinction is particularly important when individuals receive a combination of ADI healthcare, SAD assistance, privately purchased support and unpaid family care.

Privately employed caregivers, often described as badanti, may provide substantial practical support, but their employment and responsibilities are not automatically part of the public healthcare service.

Careful coordination can help clarify what they do, what remains the responsibility of healthcare professionals and what happens when the arrangement is interrupted.

At territorial level, recurring gaps between assessed need and available support may indicate wider capacity or funding pressures.

These patterns are relevant to service planning because individual continuity cannot be secured through documentation alone.

The stronger opportunity lies in using pathway information to understand where institutional boundaries are creating repeated difficulties for people and families.

Operational Scenario: Dementia, Family Carer Strain and Escalation in Lombardy

Consider an illustrative case involving an 85-year-old woman living with dementia in Lombardy. She receives assistance from her daughter and a privately employed caregiver, while territorial healthcare professionals support aspects of her clinical care.

Over several months, the woman becomes increasingly disorientated at night and occasionally attempts to leave her apartment.

Her daughter is concerned about safety but wishes to avoid unnecessary restrictions or an immediate move into residential care.

The relevant Azienda Socio Sanitaria Territoriale (ASST) and other professionals consider the clinical and functional implications. Municipal social services may also need to assess whether additional practical assistance is available.

Lombardy’s organisational terminology requires particular care. An Agenzia di Tutela della Salute (ATS) is a regional health-system organisation, while an Ambito Territoriale Sociale is a social-service territorial area. The shared abbreviation should not obscure their different responsibilities.

The woman’s changing behaviour requires more than an administrative adjustment to her existing care plan.

Professionals consider possible health factors, environmental changes, communication needs and the sustainability of the family’s support arrangement.

The daughter explains that she is losing sleep and is increasingly worried about leaving her mother with the caregiver during working hours.

The response considers appropriate clinical review, practical safety measures, the woman’s preferences and any available support for the family.

Decisions about additional municipal assistance or alternative provision remain subject to the relevant local arrangements.

If risks become urgent, the family needs clear information about the appropriate healthcare response rather than relying on a general request for a future social-service review.

The pathway also needs to avoid assuming that the daughter can indefinitely absorb additional responsibilities.

At subsequent review, professionals examine whether the interventions have improved safety and wellbeing without unnecessarily restricting the woman’s autonomy.

This scenario illustrates the importance of distinguishing clinical escalation, social-service decisions and family support while maintaining one coherent understanding of the individual’s circumstances.

Continuity Across Home Care, Rehabilitation and Residential Services

Complex care pathways frequently involve movement between settings. These transitions may include hospital discharge, temporary rehabilitation, increased home support, residential admission or return to the community.

Each transition creates an opportunity to reconsider what support is appropriate. It also introduces a risk that important information or responsibilities may be lost.

For example, a person entering an RSA may have established medication arrangements, mobility support requirements and communication preferences that are familiar to the home care team.

The receiving facility needs sufficient information to assess and deliver appropriate care, but the transition should not be treated as a simple transfer of existing instructions.

Residential professionals must undertake the assessment and planning required within their service framework.

Similarly, a person leaving rehabilitation may have improved mobility but still require assistance with daily activities or access to community services.

Continuity therefore involves both transferring relevant information and reconsidering the person’s current needs.

Appropriate management of transitions between hospital and home support is particularly relevant where clinical and social interventions must begin at different times.

Providers should understand which responsibilities they retain during a transfer and when another organisation has accepted responsibility for ongoing care.

Families should receive clear explanations about changes in services, costs and practical arrangements.

The person’s preferences remain central. A move into residential care should not automatically be treated as the inevitable outcome of increasing dependency when other appropriate options may exist.

However, preserving a preferred living arrangement must also involve realistic consideration of safety, service capacity and the sustainability of informal support.

Effective continuity is therefore not simply the absence of service interruption. It is the preservation of appropriate support, information and individual choice as circumstances change.

Workforce Coordination and the Limits of Informal Case Management

Italy’s complex care pathways depend on a diverse workforce, including doctors, nurses, rehabilitation professionals, social workers, Operatori Socio-Sanitari (OSS), residential staff and privately employed caregivers.

These workers have different professional responsibilities, employment arrangements and levels of access to information.

Coordination requires recognition of these differences rather than an assumption that every participant can undertake the same tasks.

For example, a privately employed caregiver may observe changes in appetite, mobility or behaviour, but clinical interpretation and treatment decisions remain matters for appropriately qualified professionals.

Similarly, a municipal social worker may identify a serious concern about the sustainability of home support without possessing authority to arrange specialist medical treatment.

Professional boundaries should support safe coordination rather than prevent information from reaching the appropriate person.

Workforce pressures complicate these arrangements. Rural areas may have limited access to specialist professionals, while urban services may experience substantial demand and fragmented provider networks.

Staff turnover can also affect continuity because knowledge about an individual’s circumstances may be held informally by experienced workers.

Organisations therefore need systems that preserve essential information when personnel change.

Supervision, professional development and clear communication arrangements are important components of workforce resilience and continuity.

However, the solution is not simply to appoint another coordinator to every pathway.

Additional coordination roles can improve clarity where responsibilities and authority are well defined. They can also create duplication if existing professionals remain uncertain about who makes decisions.

The stronger approach is to establish proportionate coordination arrangements that reflect the complexity of the individual’s circumstances and the organisational environment.

Families should be supported as partners, but should not be expected to substitute for essential professional coordination.

Operational Scenario: Rural Complexity and Specialist Access in Calabria

Consider an illustrative case involving a 78-year-old man living in an inland municipality in Calabria. He has chronic respiratory disease, diabetes and reduced mobility following a previous stroke.

His wife provides most daily assistance. Specialist appointments require substantial travel, and the availability of home-based professional support is affected by local workforce capacity.

Following a deterioration in his respiratory condition, the relevant territorial healthcare service reviews his needs and considers appropriate clinical monitoring and rehabilitation.

The municipality is separately involved in assessing practical support requirements.

The challenge is not only the man’s combination of conditions. It is the difficulty of coordinating services across distance, professional availability and different organisational responsibilities.

His wife reports that she is finding transfers increasingly difficult and that the cost and practical demands of travelling to appointments are becoming burdensome.

Professionals consider whether some follow-up can appropriately take place closer to home or through available remote consultation arrangements.

However, remote contact cannot replace physical assessment or hands-on intervention where these are clinically necessary.

The pathway therefore needs to establish which appointments require travel, what home interventions can realistically be provided and how changes in condition should be communicated.

When a scheduled professional visit cannot take place, the response depends on the nature of the intervention and the associated risk.

A routine appointment may be rearranged appropriately, while a clinically significant concern may require more urgent assessment.

The family needs to understand that distinction.

At territorial level, repeated difficulties with specialist access and home service coverage may indicate a wider need to examine workforce deployment and service geography.

The scenario demonstrates how rural continuity depends on practical capacity, appropriate escalation and realistic service design rather than assuming that an integrated plan guarantees immediate access.

Information Sharing, Digital Infrastructure and Pathway Visibility

Reliable information exchange is essential when several organisations contribute to one person’s care.

Italy’s Fascicolo Sanitario Elettronico (FSE) provides an important component of the national digital healthcare environment, although implementation, information availability and integration differ across regional systems.

Municipal social-service records, residential provider systems and privately arranged support may operate through separate information environments.

It would therefore be inaccurate to assume that all professionals involved in a complex pathway can access one complete electronic record.

Effective coordination requires clarity about what information is relevant, who is permitted to receive it and how changes are communicated.

Clinical information may be necessary for safe healthcare delivery, while social-service professionals may need information about functional ability, living arrangements and support networks.

Information sharing must respect the General Data Protection Regulation and applicable Italian requirements.

Privacy is particularly important where cognitive impairment, family disagreement or sensitive personal circumstances are involved.

The individual’s rights and preferences should remain visible within the lawful arrangements governing information use.

Good interoperability and system integration can reduce duplication and support timely decisions, but technical connectivity is only one part of effective coordination.

A digital platform may show that a referral was sent without demonstrating that the receiving organisation accepted responsibility or arranged the required intervention.

Similarly, a record of a completed assessment does not necessarily establish that the person received appropriate support.

The Digital Transformation Readiness Assessment can help organisations structure general questions about technology capability, information governance and implementation. It does not provide certification against Italian digital healthcare requirements.

The central objective should be to make relevant pathway information available for appropriate decisions while protecting privacy and professional accountability.

Operational Scenario: Residential Transition and Continuity of Personal Support in Piedmont

Consider an illustrative case involving an 89-year-old woman in Piedmont who has experienced several falls and increasing difficulty managing at home.

She has been receiving assistance from her niece and a privately employed caregiver, but the arrangement is becoming difficult to sustain.

Following appropriate assessment, residential care is considered among the available options.

The woman is concerned about losing contact with her neighbourhood and wishes to maintain regular visits from friends.

The relevant professionals discuss her care needs, preferences and the practical implications of different arrangements.

If an RSA placement is pursued, the pathway must address the applicable assessment and admission arrangements, service availability and financial responsibilities.

The niece also needs clear information about what support the facility will provide and whether additional personal expenditure may be involved.

During the transition, the receiving team obtains relevant information about the woman’s mobility, medication, communication preferences and previous daily routines.

However, the RSA undertakes its own assessment and develops the appropriate individualised care arrangements rather than assuming that the previous home support plan can simply continue unchanged.

After admission, the woman becomes withdrawn and expresses concern that she no longer has meaningful contact with her friends.

The residential team discusses this with her and her niece, considering how social relationships can be maintained within the facility’s practical arrangements.

Her physical safety may have improved, but that alone does not demonstrate that the transition has achieved all the outcomes important to her.

The scenario illustrates why continuity includes identity, relationships and choice alongside clinical and personal care.

It also shows that pathway governance should consider the quality of transitions after they occur, not merely whether a placement was completed.

Measuring Pathway Performance Beyond Activity and Referral Counts

Complex pathway management requires evidence that goes beyond the number of assessments, referrals or completed care plans.

These measures are useful for understanding activity, but they do not establish whether services were coordinated effectively.

Territorial organisations and providers should examine whether individuals receive appropriate interventions, whether transitions are managed safely and whether significant problems are resolved in a timely manner.

Relevant evidence may include delays between assessment and service commencement, interruptions during transitions, repeated referrals caused by incomplete information and changes in the person’s functional or social circumstances.

Feedback from individuals and families is particularly important.

A pathway may appear administratively complete while the person experiences uncertainty about appointments, inconsistent information or difficulty contacting the appropriate service.

These experiences can reveal problems that routine performance reports do not capture.

Effective quality monitoring should therefore connect service activity with continuity, individual outcomes and the experience of navigating care.

Organisations examining these relationships can use the Quality Dashboard Builder to structure general performance and assurance information, adapted to the relevant Italian organisational and regulatory context.

Indicators also require interpretation.

A high number of reassessments may reflect effective responsiveness to changing needs rather than poor initial planning.

Conversely, a low number of recorded escalations may indicate stable pathways or difficulties in recognising and reporting problems.

Governance should therefore combine quantitative information with professional review and the perspectives of people using services.

Where repeated problems emerge, the relevant organisations should consider whether the causes involve staffing, eligibility arrangements, information exchange or the design of the pathway itself.

Regional Variation, Reform Implementation and System Learning

Italy’s regional diversity creates different starting points for strengthening complex pathway management.

Some territories have established multidisciplinary relationships and developed arrangements for coordinating hospital and community services. Others face greater challenges involving workforce distribution, organisational fragmentation or the availability of practical support.

Ministerial Decree 77/2022 establishes a national framework for territorial healthcare, including Case della Comunità, Ospedali di Comunità and Centrali Operative Territoriali.

The Piano Nazionale di Ripresa e Resilienza (PNRR) has supported investment in relevant infrastructure and organisational development.

However, the existence of a facility or coordination function does not automatically establish that all associated services are fully staffed, operational or integrated with municipal assistance.

Implementation must be evaluated through actual service capability and the experience of people moving between settings.

Law 33/2023 and Legislative Decree 29/2024 reinforce the direction towards coordinated support for older people, but their practical effects depend on the implementation of the relevant provisions and arrangements.

For regional and territorial decision-makers, the stronger opportunity lies in identifying recurring pathway difficulties and translating that learning into service improvement.

This may involve strengthening professional communication, clarifying responsibilities, improving access to assessment or reconsidering how services respond to changes in need.

It may also require attention to workforce geography, transport, digital capability and the sustainability of family caregiving.

The principles of continuous improvement are relevant because pathway governance should evolve in response to evidence rather than depend solely on formal organisational agreements.

Regional flexibility can support locally appropriate solutions, but persistent differences in access and continuity require transparent examination.

The objective is not to eliminate every variation in service design. It is to ensure that variation does not obscure responsibility or leave individuals without a credible response to changing needs.

International Lessons From Italy’s Complex Care Pathways

Italy’s experience illustrates a challenge shared by many countries: complex needs do not follow the administrative boundaries through which services are organised.

Healthcare, social assistance, residential provision and family support may operate through different funding and accountability structures even when they contribute to the same individual’s wellbeing.

The transferable lesson is not that every country should reproduce Italy’s regional health organisations or municipal social-service arrangements.

Rather, effective pathway management depends on recognising institutional boundaries while establishing clear mechanisms for coordination across them.

Three principles are particularly relevant internationally.

First, individualised assessment and planning should connect to real decisions about service delivery. A comprehensive plan cannot compensate for unresolved authorisation or capacity problems.

Second, escalation arrangements should distinguish clinical urgency, social-service difficulties and organisational coordination problems. Each requires an appropriate response and accountable decision-maker.

Third, continuity should be evaluated from the perspective of the person receiving support. The transfer of records or completion of a referral is not equivalent to a successful transition.

These principles can inform different systems without assuming identical legislation, financing or professional structures.

Italy’s experience also demonstrates that family support is an important resource but should not be treated as an unlimited substitute for organised services.

As populations age and household arrangements change, the sustainability of complex pathways will increasingly depend on realistic workforce planning, accessible territorial services and effective use of information.

Conclusion

Managing complex care pathways in Italy requires more than coordination between professionals at the point of assessment. It involves maintaining a coherent response as an individual moves between healthcare, municipal assistance, home support, rehabilitation and residential services.

The country’s regional healthcare structures and separate social-service responsibilities make clear accountability particularly important. Each organisation must understand the decisions within its authority, while individuals and families need an accessible route for resolving difficulties that cross organisational boundaries.

Effective escalation is central to this approach. Clinical deterioration, interrupted practical assistance and unresolved service authorisation may affect the same person, but they require different responses. Pathway governance should make those distinctions clear without fragmenting the individual’s experience of care.

Italy’s reform direction offers opportunities to strengthen territorial coordination, improve information exchange and support more consistent approaches to complex needs. However, organisational structures and digital systems will only improve continuity when they are supported by professional capacity, reliable communication and meaningful accountability.

The strongest evidence of progress will be found in whether people receive appropriate support when their circumstances change, whether families understand the available arrangements and whether recurring problems lead to service improvement.

For Italy, the strategic challenge is to connect national ambitions for integrated support with the operational realities of regional and municipal delivery.

For other countries, the wider lesson is that continuity cannot be achieved through a single organisation or document. It emerges when responsibilities, decisions and services remain connected around the person throughout their changing care journey.