Integrating resources in social and care services for ensuring the continuity of care to frail individuals aged 65 or over. An Italian experience

Martina Giusti ^1,2* Santa De Remigis ³ Stefano Greco ³ Valerio Filippo Profeta ³ Patrizio Zanobini ⁴ Guglielmo Bonaccorsi ⁴ Marco Del Riccio ⁴ Chiara Lorini ⁴ Maurizio Di Giosia ³ Niccolo Persiani ^1,2

• ¹ Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
• ² Foundation Research Centre Studies and Actions for the Innovation in Health – SAPIS, Rome, Sicily, Italy
• ³ ASL TERAMO, Teramo, Abruzzo, Italy
• ⁴ Department of Health Sciences, University of Florence, Florence, Tuscany, Italy

Globally the ongoing reforms of the national healthcare systems are carrying out social and health services closer to users, increasingly reaching them at home. This approach addresses the challenges posed by an ageing population, chronic diseases, and social inequalities worldwide. Effective solutions require combining experience, expertise, and resources within a unified organizational model for the social and health care systems. This is particularly crucial for providing integrated care to frail individuals aged 65 or over. This article aims to explore service innovations for frail population aged 65 years or older, focusing on the integrated management of economic and professional resources in health and social services to ensure continuity of care. The Agency of Integration for Continuity between hospital and territory (AgICOT), a service financed by the Italian Ministry of Health designed for frail individuals aged 65 or over in ASL Teramo (Abruzzo, Italy) was selected as case toddy. AgICOT utilized health plans and health budgets to integrate social and health goals and resources into a single social and health care pathway, avoiding duplication of interventions, saving resources, and ensuring economic sustainability. AgICOT has demonstrated its effectiveness as organizational response to the complex needs of frail individuals aged 65 or over, ensuring high-quality social and healthcare services in a sustainable manner. The co-responsibility of various stakeholders has been the key to the success of this project, creating the conditions for transitioning from hospital-based care to person-based care in line with international recommendations on integrated care and continuity of care.