AUTHOR=Giusti Martina , De Remigis Santa , Greco Stefano , Profeta Valerio Filippo , Bonaccorsi Guglielmo , Zanobini Patrizio , Del Riccio Marco , Lorini Chiara , Di Giosia Maurizio , Persiani Niccolò 

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

JOURNAL=Frontiers in Public Health

VOLUME=Volume 13 - 2025

YEAR=2025

URL=https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2025.1562564

DOI=10.3389/fpubh.2025.1562564

ISSN=2296-2565

ABSTRACT=IntroductionGlobally 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.MethodThe 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.ResultsAgICOT 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.DiscussionAgICOT 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 considerationsThe 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.