What Can Other Countries Learn from Portugal’s Approach to Integrated Long-Term Care?

Integrated long-term care is easy to endorse in principle and difficult to deliver in practice. Older and dependent people rarely experience their needs according to the administrative boundaries used by governments. A person may move from hospital treatment to rehabilitation, home support, primary healthcare and family care within weeks, while different organisations remain responsible for each part of the journey.

Portugal offers a particularly useful case study within the Portugal Ageing, Long-Term Care & Community Support Knowledge Hub because it has spent two decades developing the Rede Nacional de Cuidados Continuados Integrados (RNCCI) as a formal bridge between healthcare and social support. The network combines inpatient, ambulatory and home-based responses and operates alongside the Serviço Nacional de Saúde (SNS), Social Security, social and solidarity-sector providers, private organisations, municipalities and families.

The lesson is not that Portugal has solved integration. It has not. Access still varies geographically, public long-term-care expenditure remains comparatively low, formal workforce capacity is constrained and families continue to absorb a substantial share of support. Integration is also stronger in some parts of the pathway than others.

That is precisely why the Portuguese experience is valuable internationally. It demonstrates what integration can achieve, where formal architecture is insufficient, and why health-social coordination depends on capacity, workforce, funding and accountability as much as organisational design. Other countries should therefore examine Portugal less as a model to copy and more as a long-running operational experiment in making fragmented responsibilities work around real people.

The first lesson is that integration needs an operational structure

Many countries describe integrated care as a policy aspiration without creating a mechanism through which integration actually occurs.

Portugal’s RNCCI provides such a mechanism.

Created as a national network of integrated continuing care, it addresses people whose needs sit between acute healthcare, rehabilitation, long-term dependency and social support. Its service types include convalescence, medium-duration rehabilitation, long-duration and maintenance, home-based continuing care through Equipas de Cuidados Continuados Integrados (ECCI) and other specialised responses.

The important principle is not the exact catalogue of services.

It is that Portugal created a recognisable pathway for people who no longer need conventional acute hospital treatment but still require coordinated health and support input.

This is highly relevant internationally because one of the most persistent weaknesses in ageing systems is the gap between hospital medicine and ordinary community support.

A person may be medically stable but still unable to walk safely, prepare food or manage personal care. If the system recognises only “hospital” and “home”, families or general social services are left to absorb the complexity between them.

Portugal’s RNCCI makes that intermediate space explicit.

That aligns closely with the wider principle of managing transitions between hospitals and home support. Integration becomes operational when people can move into services designed for the stage they are actually in rather than being forced into categories that do not match their needs.

Integration works best when it follows changing need rather than institutional ownership

One of the strongest ideas within the RNCCI is that service type should reflect the person’s changing condition.

Someone recovering after surgery may initially require intensive rehabilitation and nursing. Later, the same person may need only home-based support. Another person may experience progressive dependency requiring longer-term maintenance rather than rehabilitation.

The pathway is therefore potentially dynamic.

This matters because many systems organise care principally around institutions. Once someone enters a hospital, nursing facility or home-support programme, the organisation becomes the dominant unit of analysis.

A person-centred system asks a different question: what support does this person need now, and what should happen when that need changes?

Portugal does not always achieve perfectly fluid transitions. Waiting times and uneven capacity can interrupt movement between service types.

But the underlying architecture remains important.

It recognises that dependency has trajectories.

Other countries can adapt this principle by building review and care-planning mechanisms around changing function rather than fixed service entitlement alone.

This is especially relevant for older people after acute illness. Temporary dependency should not automatically become permanent institutional care simply because the next step in the pathway is unavailable.

Portugal shows that health-social integration does not require one organisation to own everything

Some international reform debates assume integration means organisational merger.

Portugal offers a different lesson.

The RNCCI sits across distinct health and social structures. The SNS, Social Security and different provider organisations retain separate responsibilities. The system attempts to coordinate them through a defined network rather than abolishing their institutional identities.

This approach has obvious complexity.

Different funding streams, administrative responsibilities and professional cultures remain. Yet it demonstrates that integration can be constructed across organisational boundaries rather than only through structural consolidation.

The transferable lesson is important for countries where health and social support are constitutionally, financially or administratively separate.

Complete merger may be politically unrealistic or operationally unnecessary.

The stronger requirement is clarity about interfaces:

• who assesses the person;
• who authorises or refers into the next part of the pathway;
• who funds each component;
• what information follows the person;
• who is accountable when the transition stalls; and
• how disagreement between organisations is resolved.

This is fundamentally a question of organisational structure and accountability.

The Governance Maturity Assessment can help organisations examining similar cross-boundary arrangements test whether responsibility, escalation and assurance remain clear. It does not reproduce Portuguese governance, but the underlying principle is universal: integration becomes fragile when everyone participates but nobody owns the unresolved problem.

A stroke pathway illustrates the value of intermediate care

Consider a 73-year-old man admitted to a hospital in northern Portugal after a stroke. Acute treatment stabilises his condition, but he cannot yet transfer independently, dress himself or walk safely.

Sending him directly home would place substantial demands on his wife and create a high risk of avoidable deterioration. Keeping him indefinitely in an acute hospital bed would also be inappropriate once specialist hospital treatment is no longer required.

An RNCCI rehabilitation response creates an intermediate stage.

Physiotherapy, nursing, medical oversight and other multidisciplinary support focus on recovery and functional ability. His wife becomes involved in planning without immediately becoming the sole provider of physical care.

As his mobility improves, the next objective is not simply discharge from the unit. It is a sustainable transition.

Home circumstances, family capacity, primary healthcare and any required SAD or ECCI support need to align around his return.

The scenario demonstrates a principle applicable far beyond Portugal: successful hospital flow depends on receiving-system capability.

Hospitals cannot optimise discharge in isolation if rehabilitation, home support or community care is unavailable.

This is why hospital discharge and reablement should be understood as a whole-system function rather than an acute-care performance metric.

The RNCCI also shows that integration requires real capacity

An elegant referral pathway does not create a bed, therapist, nurse or home-support worker.

This is perhaps the most important limitation in Portugal’s experience.

RNCCI architecture can define appropriate pathways, but practical access depends on the availability of relevant services in the person’s territory.

Portugal has continued expanding capacity, including substantial investment through the Plano de Recuperação e Resiliência. By August 2026, RNCCI capacity included more than 17,000 places across inpatient, home and ambulatory responses, with home-based ECCI capacity representing a significant component of the network.

That expansion matters, but demand and supply remain geographically uneven.

The international lesson is clear.

Integration cannot compensate indefinitely for scarcity.

A system can create excellent multidisciplinary assessment and still fail the person if every appropriate downstream option has a waiting list.

Countries designing integrated-care structures should therefore develop capacity planning at the same time.

The relevant question is not simply “What pathway should exist?” It is “Can the system deliver it at the scale and location required?”

The Digital Twin Scenario Modeller can support organisations examining these dependencies by modelling relationships between demand, capacity, workforce and service stability. Its relevance here is methodological: integration needs scenario planning as well as organisational design.

Home-based continuing care strengthens integration because it crosses the institutional threshold

Portugal’s recent expansion of ECCI provision is particularly instructive.

Home-based continuing care moves multidisciplinary RNCCI capability into the person’s own environment. In 2026, the Government widened a model initially tested across five ULS organisations, allowing additional ULS organisations to opt into expansion.

The initial pilot was reported to have increased the average number of people supported daily and was associated with fewer emergency-department attendances among those involved, alongside high reported satisfaction from people and carers.

These findings should be interpreted as evidence from a specific programme rather than proof that home-based continuing care will produce identical results everywhere.

The underlying lesson is nevertheless powerful.

Integration often becomes stronger when care is organised around the place where the person actually lives rather than around the institutions providing separate inputs.

At home, health, functional ability, family support, housing and ordinary daily life become impossible to separate conceptually.

A nurse may identify that medication is clinically appropriate while also recognising that the person cannot prepare food. A therapist may understand that an exercise programme is realistic only if the home environment allows safe movement. A social professional may see that the family arrangement is reaching its limit.

Home-based integrated care therefore makes complexity visible.

That is one reason home-care service models and pathways should be part of integrated-care strategy rather than treated as a residual service after institutional options are considered.

Portugal demonstrates the importance of plural provider participation

The RNCCI is not delivered exclusively through state-owned organisations.

Portugal’s social and solidarity sector, including IPSS organisations and Misericórdias, plays a major role in long-term care, alongside public and private providers. This reflects the wider Portuguese care economy, in which non-profit social organisations are deeply embedded in local communities.

Internationally, this matters because integrated systems are sometimes designed as though government can simply reorganise care through public agencies alone.

In many countries, the real delivery system is plural.

Community organisations, charities, faith-based providers, private organisations and informal networks may already provide substantial capacity.

Portugal’s experience suggests that integration should work with that provider ecology rather than ignore it.

But plural provision requires strong governance.

Participation in a network should not mean every provider operates according to entirely different expectations. Referral rules, professional standards, data requirements, funding arrangements and quality oversight need sufficient consistency for the pathway to remain coherent.

The transferable principle is therefore not simply “use non-state providers”.

It is that integrated care can combine diverse provider ownership while retaining shared pathway expectations.

Community organisations can provide something large systems often lack: local intelligence

Social and solidarity-sector organisations frequently understand communities at a level that national institutions cannot easily replicate.

A local SAD provider may know that an older person has stopped attending a café, that a spouse providing care appears exhausted or that transport difficulties are preventing attendance at healthcare appointments.

These observations may not appear immediately in formal clinical data.

Yet they can be early indicators of increasing dependency.

Portugal’s provider landscape demonstrates why integration should include information flowing upwards from community services, not simply instructions flowing down from national systems.

This matters for community partnerships. Integration becomes stronger when local organisations are treated as knowledge holders rather than only delivery contractors.

Other countries can apply this principle by building formal feedback routes through which community providers contribute to population planning, capacity decisions and service redesign.

Local intelligence is particularly important where administrative data lag behind rapidly changing conditions.

The SAD+Saúde pilot shows how integration can be tested before national scale-up

Portugal’s 2026 SAD+Saúde initiative offers another internationally relevant lesson.

The pilot was established through cooperation between the Instituto da Segurança Social and five organisations from the social and solidarity sector, one in each mainland region. It is intended to provide more integrated health and personalised home support for people with dependency, disability or incapacity.

The model should not yet be treated as established national provision.

Its value at this stage lies partly in the fact that Portugal is testing a more integrated home-support proposition before assuming that it can simply be scaled everywhere.

This is an important reform discipline.

Integrated-care models frequently sound compelling in policy documents, but operational details determine whether they work.

Piloting allows a system to examine:

• whether professional roles are sufficiently clear;
• how health and social information is shared;
• whether workforce capacity is realistic;
• how people and families experience the model;
• what additional workload integration creates; and
• whether improved outcomes justify expansion.

The international lesson is not that pilots are inherently good. Poorly evaluated pilots can remain isolated projects indefinitely.

The stronger principle is test, evaluate, adapt and then decide what should scale.

Family carers are part of integration whether systems acknowledge them or not

Portugal also demonstrates one of the uncomfortable realities of long-term care: families frequently perform the integration work that formal organisations fail to provide.

A daughter may coordinate appointments, medication, transport, home support and hospital information. A spouse may notice deterioration before any professional service. Relatives may translate between healthcare and social systems simply because they are the only people present across the whole pathway.

This contribution is substantial.

It is also risky if integration becomes dependent on families being available, confident and able to absorb unlimited responsibility.

Portugal’s Estatuto do Cuidador Informal and subsequent measures have increased formal recognition of informal carers. Respite initiatives and support arrangements are developing, while RNCCI and home services can also contribute in relevant circumstances.

The international lesson is that carers need to be visible within integrated-care design.

They should be asked what they can realistically provide. Relevant information should be shared with them appropriately. Their own health and sustainability need consideration.

This connects directly with family partnership and carer support.

Integration should reduce unnecessary coordination burden on families rather than quietly transfer professional responsibilities to them.

A Lisbon family scenario demonstrates the hidden coordination burden

Consider an 85-year-old woman living with dementia in the Lisbon metropolitan area. Her husband, aged 87, provides most day-to-day support. Their daughter manages appointments, medication collections and communication with professionals while working full time.

The woman receives primary healthcare and some home support. After an infection she is admitted to hospital and returns home with increased dependency.

Each formal service may perform its role correctly.

The hospital sends discharge information. The family doctor manages clinical follow-up. SAD workers resume visits. The daughter rearranges medication and coordinates transport. Her father provides supervision overnight.

From an organisational perspective, several services are connected.

From the family’s perspective, the daughter has become the integration infrastructure.

A stronger pathway would identify that the home arrangement itself has changed. The husband’s ability to continue providing support needs review. The daughter should not be assumed to be available indefinitely. Additional formal or respite support may be required.

The example illustrates why co-production and choice need to extend beyond asking whether a person accepts a service.

People and carers should influence how the whole support arrangement is designed.

Portugal’s experience shows that integrated care needs multidisciplinary practice, not just shared governance

Institutional integration can bring organisations together. The person’s needs still need professionals capable of working across disciplinary boundaries.

RNCCI responses involve combinations of medical, nursing, rehabilitation and social support depending on the service and individual need.

This creates an important international lesson.

Multidisciplinary care should not simply mean several professionals seeing the same person separately.

The value comes from shared objectives.

If physiotherapy aims to restore walking but home-support routines encourage unnecessary dependence, the interventions are misaligned. If a clinician changes treatment without understanding whether the person can manage it at home, clinical quality can still produce an operational problem.

Integrated practice therefore requires:

• a shared understanding of the person’s priorities;
• clarity about professional contributions;
• accessible information across the team;
• joint review when needs change; and
• a defined route for resolving conflicting assessments.

The transferable lesson lies in multidisciplinary purpose rather than multidisciplinary presence.

Workforce shortages can undermine integration even where the model is sound

Portugal also provides a warning.

Formal long-term-care workforce density remains low relative to the scale of its older population, and future demographic demand will make care workers, nurses, therapists and other professionals increasingly scarce.

Integration does not remove this workforce constraint.

In some respects it can create additional requirements because effective coordination takes time.

Multidisciplinary meetings, shared assessment, home travel, communication with families and transition planning are all productive work, but they consume workforce capacity.

Countries therefore need to avoid assuming integration is a free efficiency gain.

It may reduce duplication and prevent avoidable use of expensive services, but the coordinating infrastructure itself requires investment.

This makes workforce planning inseparable from integrated-care reform.

The Predictive Workforce Risk Module can help organisations test how workforce instability may affect service continuity. The wider lesson is that care integration should be modelled against real staffing capacity rather than ideal professional availability.

Regional variation exposes the limits of national architecture

Portugal’s RNCCI is national, but access is not experienced identically across the country.

Population ageing, provider capacity, workforce supply, travel distances and existing service infrastructure vary significantly between metropolitan and interior territories.

This demonstrates another international lesson: national integration frameworks need territorial intelligence.

A pathway that works well in Porto may require different operational support in rural Alentejo or Trás-os-Montes.

Home-based care illustrates the difference.

The same number of staff can deliver very different amounts of direct care depending on travel time. Specialist support may be harder to access physically. Families may live farther away. Digital tools may compensate for some distance while leaving physical support requirements unchanged.

The appropriate response is not to abandon national standards.

It is to distinguish consistent rights and pathway principles from flexible local implementation.

Other countries should therefore be cautious about judging integration solely by whether a national model exists. The more useful question is whether people in different regions can realistically access comparable outcomes.

Funding boundaries remain one of Portugal’s clearest unresolved challenges

The RNCCI demonstrates that services can be integrated operationally even when health and social financing remain distinct.

But Portugal also shows why funding matters.

The SNS, Social Security, provider cooperation arrangements, household contributions, private purchasing and unpaid family care all contribute to long-term care through different mechanisms.

This can create misaligned incentives.

A stronger home-support service may reduce pressure on hospitals, but the organisation financing the support may not directly capture the saving. Rehabilitation may delay long-term dependency, yet the benefit may be distributed across several future budgets. Carer respite can support labour-market participation and prevent care breakdown while appearing in accounting terms as a narrow social-support cost.

The transferable lesson is that integrated care needs integrated value analysis even where budgets remain separate.

Systems should ask who pays, who benefits and what happens elsewhere when one part of the pathway is underfunded.

The Commissioner Evidence Builder offers a practical way to structure outcome and accountability expectations across complex service arrangements. Although its terminology comes from a different purchasing environment, the core principle applies internationally: funding mechanisms should be connected to the pathway outcomes they are intended to support.

Portugal’s digital development highlights why interoperability matters more than a single system

Integrated care increasingly depends on digital information, but Portugal’s experience reinforces an important distinction.

The objective is not necessarily one universal software platform.

Different organisations perform different functions and may legitimately use different systems. The requirement is that appropriate information can move across those systems safely and meaningfully.

A hospital needs to communicate treatment and discharge information. An ECCI team needs current clinical and functional information. SAD workers may need specific risk and support information. Families may need understandable practical guidance.

The information requirement is therefore role-specific.

This makes interoperability and system integration a governance issue as much as a technical one.

Other countries can learn from this by avoiding two extremes: complete information silos and indiscriminate information sharing.

Connected care requires selective, lawful and purposeful exchange.

The Digital Transformation Readiness Assessment can help organisations test whether technology, workforce, information governance and operational design are aligned before attempting more ambitious interoperability.

Integrated care should be measured through outcomes across boundaries

Portugal’s experience also demonstrates why organisational performance measures are insufficient for integrated care.

A hospital can meet its discharge target while the person experiences an unsustainable transition home. An RNCCI unit can deliver excellent rehabilitation while the person waits for suitable community support. A SAD provider can complete every planned visit while the person’s overall dependency continues to worsen because other needs remain unmet.

Each organisation may be performing well within its own remit.

The pathway may still be failing.

Integrated-care governance therefore needs cross-boundary measures.

Useful indicators can include:

• time between clinical readiness and appropriate transition;
• functional change across rehabilitation pathways;
• unplanned readmission or emergency use where relevant;
• continuity of support after transition;
• person and carer experience;
• ability to remain in the preferred setting where appropriate; and
• whether recurring pathway problems vary by geography or provider network.

This connects with quality data and performance metrics. Integration should be judged by what happens between organisations as well as what happens within them.

The Quality Dashboard Builder can help organisations bring activity, workforce, quality and outcome indicators together. Its relevance lies in preventing one apparently successful metric from disguising deterioration elsewhere in the pathway.

Integrated care needs prevention at the front of the pathway

Portugal’s RNCCI is often most visible once dependency has already become significant.

But the broader Portuguese experience points towards another lesson: integration should begin before institutional or continuing care is needed.

Primary healthcare, healthy ageing, falls prevention, nutrition, accessible housing, social participation, carer support and rehabilitation all influence whether dependency develops or accelerates.

Long-term-care systems that begin only after a person crosses a formal eligibility threshold miss opportunities to preserve function earlier.

This does not mean every decline is preventable.

It means integrated-care planning should include prevention and early intervention as part of the same continuum.

A person does not move suddenly from “healthy” to “long-term care”. Functional decline often develops gradually.

Portugal’s policy emphasis on active and healthy ageing, home-based support and emerging integrated home models provides a basis for connecting these stages more explicitly.

The international lesson is that integration should include time as well as organisations: preventive, rehabilitative and long-term responses need to connect across the person’s trajectory.

Person-centred integration requires more than service coordination

A system can coordinate organisations effectively while still being experienced as controlling by the person.

True integration therefore needs to protect autonomy.

An older adult may prefer home support even where relatives believe residential care would be easier. Someone using rehabilitation may prioritise returning to a particular daily activity rather than improving every functional score. A person with dementia may still have strong preferences about routines, relationships and environment.

The care pathway should not simply become more efficient at making decisions about people.

It should become better at making decisions with them.

This is where person-centred planning in ageing well becomes part of integration.

Shared professional information is valuable. Shared goals with the person are more important.

Other countries can adapt this principle by ensuring integrated-care assessments include personal priorities alongside clinical and functional need.

Portugal’s experience also shows what should not be copied uncritically

International learning requires restraint.

The RNCCI is embedded in institutional conditions that other countries may not share.

Portugal has a tax-funded national health service, a distinct Social Security structure, a large social and solidarity sector, a specific legal and administrative framework for continuing care and a strong tradition of family caregiving.

A country with compulsory long-term-care insurance, highly decentralised municipal provision or predominantly private financing would require different mechanisms.

Portugal’s comparatively low public long-term-care expenditure should not be treated as evidence that integration itself creates a low-cost system. Significant costs remain with households and families.

Nor should the RNCCI’s national architecture be interpreted as proof of uniform access.

Regional capacity differences remain consequential.

These limitations are part of the learning.

The most useful international comparison identifies the underlying principle and then asks what local institution could perform the equivalent function.

Countries do not need a Portuguese RNCCI. They may need a recognisable intermediate-care pathway, shared assessment mechanism, integrated home-care model or cross-sector governance structure suited to their own legal and funding arrangements.

What other countries can adapt from Portugal

Portugal’s experience suggests several principles that can travel more easily than its institutions.

First, create an explicit space between acute healthcare and permanent long-term support. Rehabilitation and continuing care deserve their own pathways.

Second, integration can operate across separate organisations if referral, accountability, information and escalation are clearly defined.

Third, home-based multidisciplinary care can strengthen continuity, but it needs housing, family, social and workforce capacity around it.

Fourth, plural provider markets can participate in integrated networks when expectations remain sufficiently consistent.

Fifth, carers need recognition as participants in the pathway without becoming the default workforce used to compensate for formal gaps.

Sixth, integration should be measured through outcomes crossing organisational boundaries.

Finally, system architecture and service capacity must develop together.

These principles are adaptable because they address operational problems common to many ageing societies without assuming identical institutions.

The deeper lesson is that integration is a continuous governance task

Portugal’s twenty-year RNCCI experience shows that integrated care is not completed when a network is established.

Demography changes. Hospital demand changes. Workforce availability changes. Home-based technologies develop. Family structures change. New provider models emerge.

The network therefore has to keep evolving.

The 2026 expansion of ECCI and the SAD+Saúde pilot illustrate that process. Portugal is not abandoning its established architecture. It is attempting to extend integration further into the home.

This is arguably the most transferable lesson of all.

Integrated care should be governed as a continuous operating model rather than a one-off reform programme.

Leaders need recurring evidence about waiting, transitions, outcomes, workforce, regional variation and person experience. Where the same interface repeatedly creates difficulty, governance should redesign the pathway rather than simply manage each case separately.

That is the difference between coordination and learning.

Conclusion

Portugal’s experience of integrated long-term care offers international value precisely because it is neither a perfect system nor a simple model. The RNCCI has created a durable mechanism for connecting healthcare, rehabilitation, long-term dependency and social support, while recent expansion of home-based ECCI provision and experimentation through SAD+Saúde show that the model continues to evolve towards care delivered closer to people’s homes.

The strongest lessons lie beneath the institutional design. Integration needs an operational pathway, not only a policy ambition. Intermediate care matters because dependency after hospital treatment is often neither acute nor permanent. Separate organisations can work together when responsibilities, information and escalation are clear. Home-based multidisciplinary support can improve continuity, but only where workforce, housing, community services and family capacity make it sustainable. Integration also needs sufficient supply: a well-designed pathway cannot overcome persistent shortages of staff or services.

Portugal also demonstrates important cautions. Family care cannot remain an invisible subsidy, regional variation can undermine national architecture, and fragmented financing can weaken otherwise integrated delivery. These are not reasons to reject the model; they are part of what makes it instructive.

Other countries therefore have little reason to copy the RNCCI institutionally. The more valuable opportunity is to adapt its underlying logic: organise care around changing need, create deliberate bridges between sectors, measure what happens across transitions and keep redesigning the system as population, workforce and service realities change.