Waiting for Long-Term Care in Iceland: Managing Transitions Between Hospitals, Homes and Nursing Facilities

An older person can finish hospital treatment without being able to go home. Another may remain at home while a spouse provides increasing levels of care that are no longer sustainable. A third may have an approved nursing-home assessment but spend months in temporary accommodation before the permanent place they need becomes available. All three people can be described as waiting for long-term care, but the operational problem is different in each case.

This makes waiting and transition management an important part of the Iceland Ageing, Long-Term Care & Community Support Knowledge Hub. Iceland's nursing-home capacity has come under sustained pressure as population ageing increases demand and hospitals experience difficulty discharging people whose acute treatment has ended. In 2026, additional short-term nursing capacity was opened specifically for people leaving Landspítali while waiting for permanent nursing-home accommodation, illustrating how closely long-term care and acute hospital flow have become connected.

Yet the central challenge is broader than bed numbers. Waiting develops when assessment, community capacity, rehabilitation, hospital discharge, nursing-home availability and workforce supply do not move at the same pace. The strategic objective should therefore be to reduce inappropriate waiting, not simply to move people out of one queue into another. A strong system asks where the person should be, what support is required there, what is preventing the transition and whether repeated delay is evidence of a structural problem.

Waiting begins only after need has been defined

Iceland uses a formal nursing-home pre-admission assessment to determine whether a person needs permanent residential nursing care. The assessment is standardised and considers social circumstances, physical and mental health and the person's ability to perform everyday activities.

The principle is important because permanent nursing-home placement is not intended to be the automatic response to advanced age or temporary deterioration. Public policy aims to support people at home for as long as health and social services can do so appropriately.

A person should therefore reach the permanent nursing-home waiting pathway only when less intensive alternatives have been considered and their circumstances have changed to the point that remaining at home is no longer a viable long-term solution.

Once approved, the assessment is valid for twelve months. If no place has been offered during that period, it must be renewed. This creates an important governance signal: some people may wait long enough for their circumstances to change materially after the original assessment.

Waiting-list management cannot therefore operate as a static queue. A person who qualified for nursing-home care nine months earlier may now have greater physical dependency, different dementia-related needs or a changed family situation. Conversely, a person who experienced severe deterioration around hospital admission may regain some function.

The wider assessment and review of changing needs principle is essential because eligibility does not freeze the person's condition at the date of approval.

Iceland has a national register that can make waiting visible

The Directorate of Health maintains a Register of Nursing Home Pre-Admission Assessments. It contains social and health information about people seeking nursing-home care and provides an overview of the number waiting for placement.

This gives Iceland an important data asset. Waiting can be examined not simply as a total number but in relation to the characteristics and needs of people in the queue.

Recorded information includes the date of assessment, social circumstances, physical and mental health, functional ability, diagnoses, assessment results, classification of need and the nursing-home request.

The operational value lies in connecting demand to planning.

If increasing numbers of people waiting have advanced dementia, future residential capacity needs to include appropriate environmental design and workforce capability. If waiting grows disproportionately within particular health regions, geographic capacity requires attention. If more people are waiting inside hospitals, the consequences for acute services are different from a similar number supported safely at home.

Strong quality data and performance metrics should therefore turn the waiting register into more than an administrative list. The information needs to influence capacity decisions.

The headline waiting number conceals very different experiences

In June 2025, Iceland's nursing-home waiting list stood at 677 people. Planning documents around the subsequent expansion programme have described underlying waiting demand equivalent to more than 700 nursing-home places. These figures demonstrate substantial pressure, but they do not describe one uniform population.

People waiting may be:

• living at home with municipal and healthcare support;
• supported extensively by relatives;
• receiving temporary respite or nursing care;
• in a short-term waiting facility after completing hospital treatment; or
• remaining in hospital because no appropriate onward placement is available.

The distinction matters because the consequences of waiting differ significantly.

A person receiving a stable home package may reasonably prefer to wait for a suitable nursing home near family rather than accept the first place available. A person occupying an acute hospital bed after treatment has finished is in an inappropriate environment and simultaneously constrains hospital capacity. A spouse providing continuous overnight supervision may technically keep the person at home while experiencing severe hidden burden.

The strongest waiting-time measure therefore needs context. The number of people waiting should be considered alongside location, dependency, duration, deterioration, carer sustainability and the reason a transition has not occurred.

Operational scenario: two people on the same waiting list face different risks

Two older people both have approved pre-admission assessments and have waited for several months.

The first lives with her husband in Reykjavík. She has substantial mobility needs but remains cognitively well. Home nursing and municipal support are stable, adaptations have been made to the apartment and her husband is comfortable with the current arrangement. She would prefer to wait for a nursing home close to their neighbourhood rather than move further away.

The second person has advanced dementia and is still living at home with his daughter in a smaller municipality. He wakes repeatedly at night, has begun leaving the house unsafely and needs near-continuous supervision. His daughter has reduced her employment and reports severe exhaustion.

Both cases appear identical in a headline waiting figure. They are not operationally equivalent.

Waiting management should recognise that the second household has much less resilience. Additional respite, temporary nursing care or another interim response may be required while permanent placement remains unavailable.

The first person's preference for location should also be respected where risk remains manageable. Reducing the waiting list by pressuring her to accept an unsuitable placement would improve a metric while weakening person-centred care.

The governance principle is therefore prioritisation by need and consequence rather than queue position alone.

Landspítali makes the downstream impact visible

The most visible consequence of long-term care waiting occurs when people remain at Landspítali after acute treatment has finished.

In early 2026, hospital teams reported sustained numbers of people with approved nursing-home assessments waiting for onward placement. Around March, roughly 110 people were reported as waiting inside Landspítali, with new people becoming eligible each week.

The effect reaches the entire hospital.

An acute bed occupied by somebody who no longer needs acute treatment cannot be used for a new admission. Emergency-department congestion worsens when patients cannot move into wards. Planned activity can also be affected because hospital capacity is interdependent.

This demonstrates why hospital discharge and step-down care cannot be governed solely within the hospital. The cause of congestion may sit partly in long-term care capacity outside it.

For the individual, extended hospitalisation is also undesirable. Acute wards are designed around diagnosis, treatment and short stays rather than permanent life. People may lose strength, routine and autonomy while waiting. Families remain uncertain about the future, and staff can find themselves providing long-term support in environments designed for another purpose.

Urðarhvarf shows how Iceland is creating an intermediate layer

In March 2026, 100 nursing places opened at Urðarhvarf in Kópavogur under an arrangement designed specifically to relieve pressure on Landspítali. The places were intended for people with valid pre-admission assessments who had completed hospital treatment but were still waiting for permanent nursing-home residence.

The model is significant because it separates two transitions that had increasingly become combined: leaving acute hospital and entering the person's eventual permanent nursing home.

A person can now move from the hospital into an environment designed to meet nursing needs while permanent placement continues to be arranged.

The agreement was also designed with flexibility so capacity could be increased temporarily if pressure rose. Later planning envisaged up to around 130 places through that arrangement.

This is not the same as eliminating the nursing-home waiting list. It creates a more appropriate location in which some people can wait.

That distinction matters operationally. Temporary nursing capacity can improve hospital flow and resident experience without resolving the structural difference between permanent demand and supply.

If temporary places become occupied for increasingly long periods because permanent capacity remains unavailable, they can themselves become another blocked layer in the pathway.

Temporary capacity needs an explicit purpose

A short-term nursing place should not become an undefined destination.

Its purpose may be to provide appropriate nursing support while a permanent place is identified, allow rehabilitation or reassessment, or create temporary relief where a home arrangement has broken down.

Each purpose implies a different pathway.

A person waiting permanently for a nursing home needs active placement management. Somebody entering for rehabilitation needs goals, review and a potential route home. A family receiving respite needs clarity about the duration and what happens afterwards.

Iceland's formal respite framework recognises this distinction. Temporary nursing stays can last from a few days to several weeks and are intended partly to support continued living at home. Applications are handled through nursing-home pre-admission assessment committees, with a faster processing expectation than permanent assessment.

The risk arises when different forms of temporary provision blur together under capacity pressure.

A rehabilitation place occupied indefinitely by somebody waiting for permanent accommodation removes capacity from rehabilitation. A respite bed repeatedly used as a substitute for permanent placement reduces availability for families trying to prevent care breakdown.

Good pathway governance therefore protects the purpose of each intermediate resource.

Operational scenario: leaving hospital does not end the wait

An 85-year-old man with advanced frailty and cognitive impairment finishes treatment at Landspítali. A pre-admission assessment confirms that permanent nursing-home care is required. Returning to his previous home is not realistic because he now needs continuous assistance and his wife cannot safely provide it.

No permanent place matching his needs is immediately available.

Rather than remaining on an acute ward, he transfers into short-term nursing accommodation. The physical environment is more appropriate, staff are able to support long-term care needs and hospital capacity is released.

From a system perspective, this is an improvement. From the man's perspective, however, the transition remains incomplete.

His wife now travels to the temporary facility while waiting to learn where he will eventually live. Staff need sufficient information about his routines, dementia-related communication and clinical needs even though they may support him only temporarily. His eventual nursing home will then need another full handover.

If the wait becomes prolonged, leaders need to know why. Is he waiting for a particular geographic area? Is specialist dementia capacity limited? Are permanent places opening more slowly than forecast?

The case shows why a successful hospital discharge metric can coexist with an unresolved long-term care problem. The person has moved, but the pathway has not yet reached its intended destination.

Organisations examining comparable flow can use the Quality Dashboard Builder to bring together waiting duration, location, dependency, transitions and outcomes. The framework is not an Icelandic national dashboard, but it can help distinguish genuine pathway resolution from movement between queues.

Hlévangur adds further short-term capacity in 2026

Iceland's 2026 response extended beyond Urðarhvarf. Plans announced in May provided for 24 short-term nursing places at Hlévangur in Reykjanesbær, expected to reopen in the autumn after refurbishment.

These places were similarly intended for people who had completed treatment at Landspítali and held approved pre-admission assessments while awaiting permanent nursing-home placement.

Together with Urðarhvarf and reopened short-term places at Vífilsstaðir, the measures were expected to give Landspítali access to 169 short-term nursing places, representing a substantial net increase during the year.

This is a strategically important response because it recognises that acute hospital flow cannot wait for the full permanent nursing-home construction programme to mature.

But it also creates a governance obligation to track the next stage.

Short-term capacity should reduce the number of medically completed patients occupying hospital wards. If permanent nursing-home supply remains constrained, however, length of stay in temporary units will increase. Eventually, those units lose the flexibility for which they were created.

The system therefore needs to measure flow through all three stages:

• hospital treatment completed;
• transfer into appropriate temporary nursing care where necessary; and
• arrival at the permanent setting that best fits the person's needs.

No single transfer should be treated as the complete outcome if the person remains in prolonged transition.

Waiting at home can be less visible but equally consequential

Hospital waiting attracts attention because blocked beds affect highly visible acute services. People waiting at home are easier to overlook.

Some remain stable with well-designed municipal and healthcare support. Others are effectively sustained by family members providing substantial unpaid care.

A home arrangement can therefore look successful in administrative data while gradually becoming unsustainable.

An older spouse may be helping with continence, transfers and night-time supervision. An adult child may reduce working hours or visit several times each day. Home-care services may continue to record the same formal package even as informal input grows around it.

The family partnership and carer-support perspective is central to waiting-list management because households can deteriorate before formal eligibility or placement changes.

Services need to know when the person is waiting safely and when waiting is being sustained only through escalating family burden.

That requires ongoing review rather than assuming that the absence of an emergency means the existing arrangement remains appropriate.

Respite care can prevent waiting from becoming crisis

Temporary respite admission serves a different purpose from transitional places used primarily to release acute hospital capacity.

Iceland's respite arrangements can support older people who remain at home where the person providing care needs a break, becomes temporarily unavailable or where the older person needs a period of nursing care or rehabilitation.

The strategic value lies in preserving home arrangements that remain fundamentally viable.

A spouse may be able to continue caring with periodic respite but not without it. A short stay following deterioration can provide time to adjust the home-support package. Rehabilitation may restore enough ability for the person to return home rather than move permanently into residential care.

This places respite within prevention and early intervention. It can prevent both carer breakdown and avoidable permanent institutionalisation.

However, respite needs its own protected capacity. If every available nursing place is absorbed by people awaiting permanent accommodation, preventative short-term services are squeezed out.

This creates a paradox: pressure to solve today's waiting list can remove resources that help prevent tomorrow's waiting list.

Hospital discharge requires community alternatives as well as nursing homes

Not every older person who cannot return immediately to their previous arrangements needs permanent nursing-home care.

Some need intensive short-term rehabilitation. Others need temporarily increased home support, equipment, housing adaptations or a period of home nursing. Some may need transitional accommodation while mobility improves.

The quality of discharge therefore depends on the number of credible pathways available.

A system with only two practical options—return home immediately or wait for a nursing home—will inevitably overuse both hospitals and permanent residential care.

The hospital discharge and reablement principle is particularly important because function can change rapidly after acute illness.

An older person who requires substantial help on the day acute treatment ends may need much less assistance three weeks later if rehabilitation is effective. Permanent care decisions made too early can therefore institutionalise temporary dependency.

Conversely, rehabilitation should not be used simply to delay recognition that somebody now has persistent high-level needs. The purpose is to test and restore realistic capability.

Operational scenario: rehabilitation changes the destination

An 81-year-old woman living in Akureyri is admitted after a fracture. Before hospitalisation she lived independently with occasional assistance. At the end of acute treatment she requires help transferring, dressing and using the bathroom.

Her immediate level of dependency makes a direct return home unsafe, but there is uncertainty about how permanent those limitations are.

Rather than progressing immediately towards permanent nursing-home placement, she enters a time-limited rehabilitative pathway. Physiotherapy and occupational therapy focus on mobility and everyday activities, while her home situation is reviewed.

During the first two weeks she regains enough strength to transfer independently. Equipment is arranged for her bathroom and temporary municipal support is planned for her return.

She leaves rehabilitation requiring significantly less assistance than at hospital discharge.

The case does not demonstrate that rehabilitation can replace nursing homes. Another person with severe progressive dementia or profound physical dependency may have a very different trajectory.

It demonstrates why transition systems need enough time and expertise to distinguish temporary functional loss from permanent long-term care need.

Where this distinction is made well, nursing-home capacity is protected for people whose requirements genuinely cannot be met through less intensive support.

Choice of nursing home affects both dignity and flow

Placement cannot be treated purely as assigning the first available room.

Where people can express a preference, location matters. Nursing homes closer to spouses, children and established communities can help preserve relationships. Facilities may also differ in environment and specialist capability.

This creates a legitimate tension between individual choice and system flow.

A person who declines an available place because it is far from their family may remain on a waiting pathway longer. From a narrow capacity perspective, the refusal delays movement. From a person-centred perspective, permanent relocation far from social networks can have profound consequences.

The system therefore needs transparent processes around preferences and offers without turning choice into an unlimited expectation that every preferred placement will always be available immediately.

This is particularly important in a geographically dispersed country. A rural resident may have few nearby alternatives. Moving into the capital region could increase access to specialist care while weakening community connection.

The strongest transition process makes these trade-offs explicit rather than treating geographic preference as an administrative inconvenience.

Workforce determines whether planned capacity actually opens

Iceland's programme for expanding nursing-home infrastructure is substantial, with more than a thousand additional places planned across the second half of the 2020s. That provides an essential response to demographic demand.

But planned places only reduce waiting if they become staffed operational capacity.

Every new permanent or temporary facility requires nurses, practical nurses, care workers, therapists, managers, domestic staff and access to medical support. Expansion therefore competes with hospitals and community services for a limited labour pool.

This means waiting-list forecasts need a workforce model alongside the construction programme.

Opening new facilities by moving experienced staff from existing services may relocate rather than solve capacity pressure. Heavy dependence on agency or overtime can make new provision fragile. International recruitment can help but requires induction, language support, retention and career development.

The wider workforce-planning issue is therefore integral to transition management.

Organisations examining comparable expansion can use the Predictive Workforce Risk Module to test how workforce instability can constrain service capacity. Any use in Iceland would require local labour-market assumptions, but the underlying principle remains: a bed without a sustainable workforce is not usable long-term care capacity.

The planned expansion needs to be judged against population change

Iceland's construction programme is designed to reduce current waiting pressure while preparing for future demographic demand. The challenge is that these are two different tasks.

Clearing today's backlog does not create permanent surplus capacity if the number of older people requiring high-intensity care continues rising afterwards.

OECD analysis has indicated that Iceland may require roughly one hundred additional nursing-home places each year through to 2040. That scale provides useful context for the more than one thousand places planned during 2025–2029.

Planning therefore needs a moving baseline. The system should not ask simply whether the waiting list fell after a new facility opened. It should examine whether supply is keeping pace with new eligible demand.

The same applies geographically. National capacity may rise while individual regions remain underprovided. A facility opening in one area can reduce national waiting figures without materially improving access for people who need to remain close to families elsewhere.

The Digital Twin Scenario Modeller offers organisations exploring similar planning questions a way to test alternative assumptions around capacity, workforce and demand. It is not a forecast of Iceland's nursing-home needs, but scenario planning is particularly valuable where current backlog and long-term demographic growth overlap.

Transition quality matters because people can experience repeated moves

One unintended consequence of creating intermediate capacity is the possibility that frail older people experience several moves in a relatively short period.

A person may move from home to hospital, from hospital to a temporary nursing facility and later from that facility to a permanent nursing home.

Each transfer can involve new staff, unfamiliar routines, repeated assessment, new medication processes and disruption of family visiting patterns.

For people with dementia, repeated environmental change can be particularly difficult. Orientation can worsen and distress can increase when familiar cues disappear.

Transition management therefore needs to minimise avoidable duplication.

Information gathered during hospital and pre-admission assessment should follow the person appropriately. Temporary nursing staff should record changes that matter to the permanent home. Life-story information, communication needs, medication, mobility, nutrition and safeguarding concerns all need continuity.

The broader dementia transition and escalation principle is especially relevant because a technically successful transfer can still produce a poor human experience.

The strongest pathway treats each transition as part of one continuous journey rather than a new episode beginning from zero.

Operational scenario: repeated transfers create avoidable deterioration

A 90-year-old woman with dementia is admitted to hospital from home after an infection. Following treatment, her nursing-home assessment is approved because her needs have become too intensive for the previous home arrangement.

She moves first into temporary nursing accommodation while waiting for a permanent place. During the transfer, most clinical information arrives, but limited detail is provided about her preferred routines, how she expresses pain and what usually reduces distress.

She becomes unsettled and begins walking around at night. Staff initially interpret this as a deterioration in dementia. Her daughter later explains that she has always slept late and often walked around the house when anxious.

Several weeks later she moves again to her permanent nursing home.

A stronger process transfers not only diagnoses and medication but the practical knowledge accumulated during the temporary stay. Staff at the permanent home know what helped her settle, how she communicates discomfort and which routines matter.

The scenario demonstrates why transition quality should be measured across organisational boundaries. Repeated moves may sometimes be unavoidable, but repeated loss of information is not.

For frail people, continuity itself is a safety and quality intervention.

Data should identify where the pathway is actually blocked

Waiting-list governance becomes much stronger when leaders can identify the location of delay.

A single total waiting figure cannot distinguish between a shortage of permanent nursing-home places, delayed assessment, insufficient temporary capacity, rehabilitation bottlenecks or people choosing to wait for particular locations.

A more useful flow model tracks stages.

For example, leaders may examine the time between hospital treatment completion and assessment, the time from assessment approval to temporary transfer, duration in temporary nursing care and time to permanent placement.

Patterns can then be investigated.

If pre-admission assessment is slow, adding nursing-home beds will not solve that delay. If people enter temporary facilities quickly but remain there for months, permanent capacity is the larger constraint. If a high proportion of permanent places cannot open because of recruitment, workforce rather than construction has become the limiting factor.

This is the purpose of quality monitoring systems: not simply to describe pressure, but to locate where intervention can change it.

Governance needs to connect ministries, healthcare and municipalities

Long-term care waiting crosses organisational boundaries by design.

National government influences healthcare policy, nursing-home financing and capital expansion. The Directorate of Health oversees assessment data and quality information. Healthcare institutions manage acute treatment and many clinical transitions. Municipalities are responsible for social support that may determine whether a person can remain at home while waiting or avoid permanent placement altogether.

No single organisation can therefore solve the transition problem independently.

A hospital can improve discharge coordination but cannot create municipal home-care capacity. A municipality can strengthen support at home but cannot open a permanent nursing-home place. Building programmes can expand capacity but cannot operate without workforce.

The governance challenge is to make interdependence explicit.

The Governance Maturity Assessment can help organisations examine whether responsibility, evidence and escalation are sufficiently connected. It is not an Icelandic governance framework, but its underlying question is highly relevant: does recurring delay travel far enough through the system to reach the level capable of changing it?

Waiting should be managed by risk as well as time

Elapsed waiting time is important because prolonged uncertainty can harm people and families. But time alone should not determine urgency.

A person waiting six months in a stable, well-supported home arrangement may face less immediate risk than somebody waiting six weeks in a household close to breakdown.

Prioritisation therefore needs to remain sensitive to changing need.

Relevant factors can include deterioration in cognition, repeated falls, increasing hospital use, carer breakdown, inability to provide overnight support and the emergence of safeguarding concerns.

This does not mean moving people arbitrarily ahead of others. It means recognising that clinical and social risk changes while a person waits.

The waiting list should therefore be a managed population rather than an ordered spreadsheet.

Reducing delay must not reduce choice and dignity

Pressure on hospitals and waiting lists can create understandable incentives to accelerate movement. Yet transition targets can become harmful if they make the organisational objective more important than the person's experience.

An older person should not be treated as a unit of blocked capacity.

Their move may involve leaving a home of several decades, separation from a spouse, relocation to another community and acceptance that permanent high-level care is now required. These decisions carry emotional and identity consequences alongside operational ones.

Families need clear information about why a particular setting is proposed, what alternatives exist and what happens while waiting. People using services should be involved as far as possible in location and transition decisions.

The choice and control principle is therefore relevant even where capacity is constrained. Scarcity may limit available options, but it does not remove the obligation to communicate honestly and involve people meaningfully.

The strongest future model is a managed continuum, not a larger queue

Iceland's current investment in short-term and permanent nursing capacity is necessary. Urðarhvarf, the reopening of additional short-term places and the wider construction programme all respond to real pressure that has affected Landspítali and older people waiting for appropriate care.

The next stage needs to ensure that capacity operates as one continuum.

Home support should prevent avoidable escalation where possible. Rehabilitation should restore function before permanent dependency is assumed. Pre-admission assessment should identify genuine nursing-home need. Temporary facilities should provide appropriate care while transitions continue. Permanent nursing homes should receive people whose needs require that level of support.

Every layer needs enough capacity to perform its intended function.

If one layer blocks, pressure moves backwards: nursing-home shortages fill temporary units; full temporary units leave people in hospital; hospital congestion affects emergency care; inadequate home support can accelerate entry into the entire pathway.

The strategic task is therefore flow management across the whole care system rather than isolated waiting-list reduction.

International learning: delayed discharge is usually an interface problem

Iceland's specific response reflects its own public healthcare system, municipal responsibilities, small population and nursing-home financing arrangements. Other countries may organise long-term care very differently.

The transferable lesson lies in recognising what delayed discharge represents.

A hospital occupied by people who no longer need acute treatment often signals constraints beyond the hospital. Building additional acute beds can temporarily absorb pressure without resolving the long-term care pathway beneath it.

Iceland's use of short-term nursing capacity illustrates one possible response: move people into a more appropriate environment while permanent capacity expands. The mechanism cannot simply be copied everywhere, but the principle is useful.

Transitions need intermediate options. Waiting data need enough detail to identify bottlenecks. Workforce needs to be planned alongside buildings. Family burden needs to remain visible alongside institutional waiting. Above all, success should be defined by reaching the right setting rather than merely leaving the previous one.

Conclusion

Waiting for long-term care in Iceland is not a single queue and cannot be solved through a single intervention. Some people wait safely at home, others rely on relatives whose capacity is becoming fragile, while others complete hospital treatment but cannot move directly into the permanent nursing care they require. The consequences reach from individual households into Landspítali and the wider health system.

Iceland's 2026 expansion of short-term nursing capacity is an important operational response because it provides a more appropriate setting for people who have completed acute treatment while permanent placement remains unavailable. The wider nursing-home construction programme is equally necessary. But additional places will achieve their full value only if assessment, rehabilitation, workforce, municipal support and placement processes develop alongside them.

The strongest governance model treats waiting as a flow problem across the entire continuum. It asks where each person is waiting, whether that setting remains appropriate, what is preventing the next transition and whether repeated delay points to a structural weakness requiring action beyond the individual case.

For Iceland, reducing long-term care waiting should therefore mean more than producing a smaller headline number. The real objective is timely movement into the right support, with fewer unnecessary hospital days, fewer exhausted households, better continuity between settings and enough capacity at every stage to preserve dignity, safety and meaningful choice.