Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 May 21:13:1562564.
doi: 10.3389/fpubh.2025.1562564. eCollection 2025.

Integration of resources in social and healthcare 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 , Guglielmo Bonaccorsi  4 , Patrizio Zanobini  4 , Marco Del Riccio  4 , Chiara Lorini  4 , Maurizio Di Giosia  3 , Niccolò Persiani  1   2
Affiliations

Integration of resources in social and healthcare services for ensuring the continuity of care to frail individuals aged 65 or over: an Italian experience

Martina Giusti et al. Front Public Health. .

Abstract

Introduction: 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 population aging, chronic diseases, and social inequalities. Effective solutions require combining experience, expertise, and resources within a unified organizational model for the social and health care services provision. 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.

Method: 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 Local Health Authority of Teramo (Abruzzo, Italy) was selected as case study.

Results: 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 of social and healthcare systems.

Discussion: 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.

Final considerations: The co-responsibility of various stakeholders has been the key to the success of this project, creating the conditions for transitioning from hospital-based to person-based social and healthcare in line with international recommendations on integrated care and continuity of care.

Keywords: collaborative network; continuity of care; frail individuals aged 65 or over; integrated social-health care; organizational model.

PubMed Disclaimer

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
The 10 most frequent pathologies of persons assisted by AgICOT.
Figure 2
Figure 2
Communication with AgICOT stakeholders.
Figure 3
Figure 3
Coding tree by interviews.
See this image and copyright information in PMC

Similar articles

See all similar articles

References

    1. Michel JP, Leonardi M, Martin M, Prina M. WHO's report for the decade of healthy ageing 2021–30 sets the stage for globally comparable data on healthy ageing. Lancet Healthy Longev. (2021) 2:e121–2. 10.1016/S2666-7568(21)00002-7 - DOI - PubMed
    1. Rudnicka E, Napierała P, Podfigurna A, Meczekalski B, Smolarczyk R, Grymowicz M. The world health organization (WHO) approach to healthy ageing. Maturitas. (2020) 139:6–11. 10.1016/j.maturitas.2020.05.018 - DOI - PMC - PubMed
    1. Jones CH, Dolsten M. Healthcare on the brink: navigating the challenges of an aging society in the United States. NPJ Aging. (2024) 10:22. 10.1038/s41514-024-00148-2 - DOI - PMC - PubMed
    1. Oliver D. 21st century health services for an ageing population: 10 challenges for general practice. Br J Gen Pract. (2012) 62:396–7. 10.3399/bjgp12X653435 - DOI - PMC - PubMed
    1. ISTAT . Rapporto annual 2024 La situazione del Paese. Roma: (2024).

MeSH terms

LinkOut - more resources