LTCcovid Country Profiles

Responses to 1.06. Care coordination

The LTCcovid International Living report is a “wiki-style” report addressing 68 questions on characteristics of Long-Term Care (LTC) systems, impacts of COVID-19 on LTC, measures adopted to mitigate these impacts and new reforms countries are adopting to address structural problems in LTC systems and to improved preparedness for future events. It was compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project moderated the entries and edited as needed. It was updated regularly until the end of 2022.

The report can be read by question/topic (below) or by country: COVID-19 and Long-Term Care country profiles.

To cite this report (please note the date in which it was consulted as the contents changes over time):

Comas-Herrera A, Marczak J, Byrd W, Lorenz-Dant K, Patel D, Pharoah D (eds.) and LTCcovid contributors.  (2022) LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science.

Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.




Most countries have made an active effort to facilitate coordinated care, at least at policy level. Despite the policy efforts, as described in sections 1.00 and 1.02., responsibility for long-term care is fragmented, in very complex ways in some countries. LTC services are often separate from health services and countries frequently distribute responsibility for LTC across national, regional and local actors. Shortcomings have been identified in health and social care coordination/integration across countries at both national and local level undermining the performance of care provision.

LTC fragmentation and its practical implications

Analyses of integrated care policies in European countries indicate that although at governmental level integration documents tend to be produced involving health and social care sectors, at regional and local level integration between health and social care services often involves separate coordination institutions for each of the sectors (source: In practice the fragmentation of the care system affects not only the delivery of services, but can also be seen during needs assessment, when accessing benefits and packages, in data collection and in the diversity of quality improvement efforts. Fragmentation of services has been linked to dual administrative procedures, hindrances in access to care and longer waiting times (Spasova et al. 2018) and has been identified as a barrier to reducing hospitalization for ambulatory care sensitive conditions (source: WHO). In many countries, an absence of coordination between different sectors  (health, social care, public health, housing, transportation) often translates to parallel but not aligned systems for oversight, financing, staffing, and collection/management of data (source:  Other more intangible factors pertaining to the health and social care divide include values and social standing of professionals (hierarchies) that impact the joint working of staff (source:

Research evidence on (cost) effectiveness of coordinated care

Some emerging evidence indicated that integrated care has potential for service efficiencies and can have a positive impact on outcomes of people with care needs. For example, among the different types of integrated care models, Chronic Case Model (CCM) appears to have the greatest potential for improving effectiveness and cost-savings through reducing A&E visits, hospital emergency admissions and length of hospital. Studies illustrate that Case Management (CM) tend not to have positive effects, especially if used as a stand-alone measure (see literature reviews, e.g. Nolte & Pitchforth, 2014; Damery et al., 2016).

Some evidence also exists that large pooled budgets may be effective, however,  pooled budgets may also uncover unmet need thus leading to increased costs (Weatherly et al., 2010; Mason et al., 2015).


Damery, S., Flanagan, S. Combes, G. (2016). Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews. BMJ Open, 2016, 1-31, 10.1136/bmjopen-2016-011952.

MASON, A., GODDARD, M., WEATHERLY, H. & CHALKLEY, M. 2015. Integrating funds for health and social care: An evidence review. J Health Serv Res Policy, 20, 177-188, 10.1177/1355819614566832.

Nolte, E. Pitchforth, E. (2014). What is the evidence on the economic impacts of integrated care? European Observatory on Health Systems and Policies

Spasova, Slavina, Baeten, Rita & Vanhercke, Bart. (2018). Challenges in long-term care in Europe. Eurohealth, 24 (?4)?, 7 – 12. European Observatory on Health Systems and Policies, World Health Organization. Regional Office for Europe.

WEATHERLY, H., MASON, A., GODDARD, M. & WRIGHT, K. (2010). Financial Integration across Health and Social Care: Evidence Review. Edinburgh: Scottish Government.

International reports and sources

The CEQUA project provides an overview of policies on integration in 11 European countries including England, France, Germany, Spain, Sweden, Finland, Austria, Poland, Latvia, Bulgaria, Czech Republic and Italy. There are also two case studies on integrated care, from Sweden and from France (

WHO’s Regional Office for Europe has developed a framework for LTC integrated care and has published detailed country reports online.

The aged care system is difficult to access and navigate. The Royal Commission into Aged Care Quality and Safety found that people needing care found the experience to be time-consuming, overwhelming, and intimidating. The Royal Commission also expressed concern regarding the ability for people to make informed decisions due to the lack of information available.

LTC sector has been found to have less access to services, including health services. The Royal Commission into Aged Care Quality and Safety recommends the Australian Government to increase coordination by creating Medicare Benefits Schedule items to increase the provision of allied health services, including mental health services (Royal Commission, 2021).


Royal Commission into Aged Care Quality and Safety (2021) Final Report: Care, Dignity and Respect, volume 1. Commonwealth of Australia.

Last updated: February 15th, 2022

There is a lack of integration between health and social care both at a national and provincial level. Healthcare is broadly regulated by the Canada Health Act but provinces have jurisdiction over the operational aspects, funding, and services offered. Social care, including home and continuing care, are not covered under the Canada Health Act. Although the health and social care sectors are not governed under the same regulations, it is the same five regional health authorities providing both social and health care. The system is fragmented and power dynamics are difficult to understand (source:

Last updated: February 11th, 2022

Coherence and coordination in service delivery is a stated goal of the Danish Health Act of 2005 and one of the key drivers behind the major reform of local government of 2007. In reducing the number of municipalities and administrative regions, the reform effectively represented a large step towards centralizing health and social services and has actively pursued the coordination between the administrative regions and municipalities in providing care. The Danish Health Authority has also established chronic disease management strategies that bring together efforts by the administrative regions and the municipalities under a single model.

There is a good level of integration of care across providers, people who need long-term care following hospital discharge, the hospital discharge management team works closely with the general practitioner and local home services. The administrative regions are responsible for coordinating after-hours care. After-hours clinics tend to be associated with hospital emergency department  (WHO, 2019).

An example of the integrated health and social care approach in Denmark is the preventive home visits (Forebyggende hjemmebesøg). Since 1996, municipalities have been obliged to conduct a preventive home visit for older people 80+, and from 1 July 1998 this included older people aged 75+. With improvements in functional ability the age limit has been raised again to 80+.

The visits are to be offered according to need, although at least twice a year. The visit is conducted on acceptance by the older person. It should allow the older person and the assessor to evaluate the need for help and care in order that older persons can make use of their own resources, maintain full functional abilities as long as possible, and enhance their social network. Visits may also be made to older people living in nursing homes if the municipal board decides so. The municipal board may also decide to make exceptional visits in relation to the death of a spouse, serious illness or discharge from hospital. Some municipalities offer the visit from the age of 65 years for older persons with non-Danish origin, as they have often had more strenuous work lives. The person making the visit must have thorough knowledge of general social as well as health issues.

Another example is the coordinated assessment of patients in the discharge process (Fremskudt visitation). A municipal assessor is present at the hospital weekly. Based on conversations with staff, patients and informal carers, the assessor is to assess the patient’s functional abilities and coordinate that services are in place before the actual discharge. This has proven especially important for frail older people and ensures that they feel more secure and that they do not need to wait for service delivery. It also has the potential to keep costs down and prevent readmission to hospital (Buch et al, 2016).


Buch, M.S.; Jakobsen, M.; Kolodziejczyk, C. and Ladekjær, E. (2016) Evaluering af indsats for forløbskoordination – Erfaringer med fremskudt visitation i fire kommuner. København: KORA.

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at:

Last updated: June 5th, 2023

Since the beginning of the 1990s there has been an effort to integrate home care at local level between social care home services and home health care, this is in the context of home care being considered as key to support people living independently for as long as possible. In 2004 a temporary law on the structural integration of health and social care was passed to remove legal obstacles to integrate home care. These processes, which at local level has involved the merger of municipal health unites with health and welfare departments, have led to more integrated care practices (Linnosmaa and Saaksvuori, 2017).

However, despite attempts at standardization of care services across the nation, there are major differences between municipalities due to their demographics; this appears to affect individuals ability to navigate the system (Ylinen et al., 2021).


Linnosmaa I and Saaksvuori L (2017) Long-Term Care policy in Finland. Policy Brief. CEQUA LTC network.

Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021.

Last updated: February 1st, 2022

Coordination in the care sector is a longstanding preoccupation of the state and a response to the highly fragmented organization and funding of health, social and the need for ‘medico-social’  interventions in the care field.

Some level of integration at a local authority level has also been achieved through pathways and networks generally around gerontology and independence loss, as well as regional support networks and local information centres (source:

Various schemes have been developed since 2010– the PTA, the MAIA, and PAERPA schemes – having in common the creation of specific functions or professionals to support the social, medico-social and health professionals in their coordination tasks. Since, other arrangements have been developed in including the DAC (schemes to promote coordination) which should merge all other schemes excepting for CLICs which are organised by local authorities.

From a public policy perspective, the analysis of these developments shows that despite their initial objective of improving coordination between the health, social and medico-social interventions and facilities, the creation of three dedicated coordination schemes has also contributed to the complexity of elderly care professional and organizational landscape. Research also highlights limited accountability with poor transparency for users, prospective users and carers  (source: CEQUA France Country report (

Last updated: January 6th, 2022   Contributors: Camille Oung  |  Alis Sopadzhiyan  |  

Organisational silos pose challenges to care coordination

A report provided by the German Society of Nursing Science focusing on domiciliary care highlights that structural barriers exist through the organisational silos in which service providers work. Data protection causes additional challenges to the effective communication between service providers, such as domiciliary care workers and GPs. Communication and coordination between different service providers are often not part of the services for which the care providers can be reimbursed by the LTC insurance and case conferences across professions are not established, requiring domiciliary care providers and GPs to coordinate services without an established framework (Fischer et al., 2021)


Fischer, T., Kopke, K., Sirsch, E., Büker, C., Graffmann-Weschke, K., Horn, A., Junius-Walker, U., Kümpers, S. & Meyer, G. (2021) S1 Leitlinie Häusliche Versorgung, soziale Teilhabe und Lebensqualität bei Menschen mit Pflegebedürftigkeit im Kontext ambulanter Pflege unter den Bedingungen der COVID-19-Pandemie – Living Guideline. Available at: (Accessed 31 January 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

The line between medical and functional assistance is unclear. The tendency is to leave patients in their homes (community-based care), with the primary task of LTC defined as practical, mental and social assistance in functioning, with limited medical intervention.  The Israeli healthcare system is a national health insurance plan that provides universal coverage to all Israelis. All residents register with one of four competing non-profit health plans (HP’s).  The HP’s are responsible for geriatric and complex care (source: Traub Centre). Community LTC  is a branch of social insurance while institutional LTC is under the supervision of the Ministry of Health (MoH) and the Ministry of Welfare and Social Affairs (MoWSA) . A large percentage of LTC is privately funded  and there is a widespread culture of unpaid caregiving.

Last updated: February 11th, 2022   Contributors: Sharona Tsadok-Rosenbluth  |  

The Italian care system remains fragmented, which relates to the fact that the essential functions (e.g. health and social care as well as care training) are decentralized and managed at regional level. There is an increasing trend to reorganize the LTC system via ‘decentralisation’ of the health and social care, from the national to the regional and local level. In the social care sector, this development has led local administrations to develop their own LTC policies. The State-Regions Conference is the only body in charge of ensuring inter-institutional coordination (Barbarella et al. 2018).


Barbarella F, Casanova G, Chiatti C and Lamura G (2018), ‘Italy: emerging policy developments in the long-term care sector’. CEQUA LTC network report. Retrieved from Italy Country Report

Last updated: February 4th, 2022

LTC services include some nursing, so much of what we would count as healthcare comes under LTC. Individuals are assigned a care manager on becoming eligible for care and, if the person is in hospital, they facilitate discharge. At a national level, the LTC and health systems are reviewed together every 6 years – this is where provider rates and regulations are reviewed (Curry et al. 2018). Japan has an ambition to create integrated care communities but these are wider than health and care and include community services and voluntary organisations too (Morikawa, 2014). Individuals assessed and deemed to have care needs are assigned a care manager who helps people to navigate the system (Tamiya et al. 2011).


Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from:

Morikawa, M. (2014). ‘Towards community-based integrated care: trends and issues in Japan’s long-term care policy’. International Journal of Integrated Care. Retrieved from: Japan’s long-term care policy (

Tamiya et al. (2011). Population ageing and wellbeing: lessons from Japan’s long-term care insurance policy. Lancet. doi: 10.1016/S0140-6736(11)61176-8

Last updated: February 10th, 2022

The Netherlands has been experimenting with various integrated care initiatives over the past years (source: WHO | World Health Organization).

Last updated: February 1st, 2022

LTC in Poland is organised by national health care and local social services. The coordination of activities between sectors has been hampered by different governance priorities. The health sector concentrates on the long-term goals formulated in the National Health Programme. In the social services sector, ‘senior policy’ was formulated, aimed at the social activation (e.g. day care facilities) and social integration of older people (Golinowska et al. 2017).


Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report

Last updated: February 10th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

Care integration is high on the policy agenda in Singapore. For example, to facilitate integrated delivery of support and services, Singapore has consolidated aging, health, and LTC under the Ministry of Health (MOH) with inter-ministerial remits, where relevant.

The Agency for Integrated Care has taken on the role of a National Care Integrator since 2009. It is the agency’s role to match people with LTC needs with available services. The agency further is ‘responsible for supporting community care service partners in manpower development, quality improvement, programme development, and crisis management’.

In 2012, a Regional Health System model was introduced by the Ministry of Health to support the provision of ‘seamless integrated care based on geographic location’. This model facilitates local collaboration and transitions between care settings and has been reported to strengthen management capabilities and continuity of care. Key actors are designated anchor public acute hospitals as well as ‘primary, chronic health and social care’ services in the different geographic areas.

Last updated: January 6th, 2022

The provision of LTC in Spain is fragmented, due to the intervention of many agents and the differences between the autonomic regions. There have been several initiatives to improve care coordination through: the creation of social and healthcare coordination structures, the implementation of shared information systems, improving the comprehensive assistance in social centres and promoting the creation of hospital assistance units of continuity (Guillen et al., 2017).

A published study aimed to analyse the residential care crisis in Spain in the context of the COVID-19 pandemic and its impact on high mortality and abandonment of the user population. The theoretical focus of the analysis was the comprehensive and person-centred care (CPCC) model based on the autonomy of people and the centrality of their rights. The study concludes by proposing a comprehensive reform of long-term care that includes both a change in residential care in the form of small cohabitation units and reinforcement of care in the home and the community as a growing preference for the elderly population. An optimal combination of residential and home care is the basic proposal of this work (Gallego et al., 2021).


Gallego, V. M., Codorniu, J. M., & Cabrero, G. R. (2021, January 1). The impact of COVID-19 on the elderly dependent population in spain with special reference to the residential care sector. Ciencia e Saude Coletiva. Associacao Brasileira de Pos – Graduacao em Saude Coletiva.

Guillen M. et al. (2017) Country Report – Spain. Quality and cost-effectiveness in long-term care and dependency prevention. CEQUA LTC Network.

Last updated: February 10th, 2022   Contributors: William Byrd  |  

Integrated care is an explicit policy goal in Sweden. The law in Sweden stipulates that municipalities and country councils should cooperate, and that individual care plans should be established as a person begins to require services from both the municipal social services and the health sector. This is to ensure coordinated care and continuity.

However, the Swedish system is highly decentralised, and the country faces great challenges of care coordination between health and social care services for older people.  It has been suggested that the increased privatisation – introduced to mitigate financial strain on the system and inefficiencies – has made it even more challenging to cordinate care for individuals with complex needs (Lijas et al., 2019). Additionally, autonomy in the organisation and provision of long-term care at a local level means that the national level is unable to enforce structures for co-ordination (Johansson and Schoen, 2017).

According to an OECD report, the rate of Chronic Obstructive Pulmonary Disease (COPD) in elderly patients (over 80 years old) in Sweden is one of the highest in the OECD countries, suggesting there is scope for hospitalisations to be reduced through better coordination of care.

The Norrtaelje Model is a Swedish initiative, one of the key goals of which is to promote a common health and social care organisation to achieve greater user benefit (Back & Calltorp, 2015).


Bäck, M. A., & Calltorp, J. (2015). The Norrtaelje model: a unique model for integrated health and social care in Sweden. International journal of integrated care15, e016.

Johansson, L. and Schoen P. (2017) Country report for Sweden. CEQUA LTC network.

Liljas, A., Brattström, F., Burström, B., Schön, P., & Agerholm, J. (2019). Impact of Integrated Care on Patient-Related Outcomes Among Older People – A Systematic Review. International journal of integrated care19(3), 6.

Last updated: February 10th, 2022   Contributors: Daisy Pharoah  |  

There is a clear policy drive towards integrated care in England. Health care has traditionally been coordinated through local National Health Service (NHS) planning and provider organisations, which are accountable to the national government. In contrast, social care contrast is under the responsibility of local authorities, which have their own governance structures and are accountable to elected local governments. Local authorities can make their own decisions about implementation and funding allocation. Since the late 1990s to 2010 the government focused on the structural elements of partnership through multiple policy reforms. A review of progress in that period concluded that there was insufficient attention to supporting joint working through building relationships and trust (Glasby et al, 2011).

Since 2010, England introduced initiatives to encourage better integration between health and social care, building on previous efforts to improve partnerships between the two sectors. A study by Miller et al. (2020) reviewing progress on integrated health and social care in England from 2010 to 2020 has concluded that a focus on locally relevant and specific tasks or issues has resulted in the greatest progress. Broader ill-defined goals and constant policy changes are not helpful (Miller et al, 2020).

Lewis et al., (2021) conducted a review of the findings from three key integration pilot programmes (Integrated Care Pilots, Integrated Care and Support Pioneers, and New Care Model ‘Vanguards’ highlights the challenges of identifying the objectives of integrated care). All three programmes shared the aim of improving coordination between hospital and community-based health services and between health and social care. However, over time, the NHS narrowed the lens used to evaluate their success to impact on reducing unplanned hospital admissions, which led to a diminished role for local authorities and voluntary sector partners. The evaluations of the pilots show that integration is a long-term project and that reductions in unplanned hospital admissions are not necessarily the best way to measure success (Lewis et al, 2021).

The NHS Long Term Plan published in 2019 announced Integrated Care Systems (ICS) everywhere by April 2021, bringing together local organisations to deliver a ‘triple integration’ of primary and specialist care, physical and mental health services, and heath and social care. These ICSs are rooted in the NHS, with the expectation that local authorities, the voluntary sector and others will partner with them.

The plan also includes the expansion of the Enhanced Health in Care Homes model to the whole country by 2023/4 to strengthen links between primary care networks and care homes.

The Plan announces support for local approaches to blending health and social care budgets and that a forthcoming green paper on adult social care will set out further proposals for social care and health integration.


Glasby J, Dickinson H, Miller R. Partnership working in England – where we are now and where we’ve come from. International Journal of Integrated Care. 7 March 2011; 11: 1–8. DOI:

Lewis, R. Q., Checkland, K., Durand, M. A., Ling, T., Mays, N., Roland, M., & Smith, J. A. (2021). Integrated Care in England – what can we Learn from a Decade of National Pilot Programmes?. International Journal of Integrated Care, 21(S2), 5. DOI:

Miller, R., Glasby, J., & Dickinson, H. (2021). Integrated Health and Social Care in England: Ten Years On. International Journal of Integrated Care, 21(S2), 6. DOI:

Last updated: March 8th, 2022   Contributors: Adelina Comas-Herrera  |  Chris Hatton  |  

Anyone who is eligible to receive social care services in Scotland has the option of choosing Self-Directed Support for their care. Self-Directed Support was introduced in Scotland in April 2014. This option gives individuals greater control over how they receive their care and allows them to personalise their care in a way that suits them. A Public Health Scotland report on social care estimated that in 2018/19, around 79.4% people used self-directed support to make choices about their care (Source: Insights in Social Care: Statistics for Scotland). However, an Audit Scotland report suggested that the accuracy of data regarding self-directed support required improvement (Source: Self-directed support: 2017 progress report).

Last updated: March 10th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

Despite Medicaid and Medicare’s central role in the funding of LTC services, the LTC and health care sectors are not integrated. Differences in how medical care and LTC are paid for, and prioritized in each state, as well as the ownership of healthcare organizations (i.e. hospitals) compared to the LTC sector, hampers coordination of services as well as opportunities for a joint care delivery system (Dawson et al. 2021).


Dawson, W. D., Boucher, N. A., Stone, R., & Van Houtven, C. H. (2021). COVID-19: The Time for Collaboration Between Long-Term Services and Supports, Health Care Systems, and Public Health Is Now. The Milbank Quarterly, 99(2), 565–594.

Last updated: February 11th, 2022

The Catalan Government Plan for the XII legislature, approved on September 25, 2018, highlighted the need to deploy a unique strategy of integrated social and health care due to the health and social needs of the population, especially for those people who are older or have complex needs. It was agreed to redefine the Interdepartmental Plan for Social and Health Care and Interaction (PIAISS), which was replaced by the new Integrated Social and Health Care Plan (PAISS).
The aim was, in short, to create a model of integrated care for health and social services, drawing up a work plan that would help to generate a model of coordinated global intervention, with the same overall vision, which would place the person at the center.

Last updated: March 3rd, 2022   Contributors: Cèlia Estruch  |  

Contributors to the LTCcovid Living International Report, so far:

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica BreuerJorge Browne Salas, Jenni Burton, William Byrd, Sara CharlesworthAdelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin HämelNina Hemmings, David Henderson, Kathryn Hinsliff-Smith, Iva Holmerova, Stefania Ilinca, Hongsoo Kim, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, Martina Paulikova, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. SchmidtAgnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jae Yoon Yi, Jessica J. Yu

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.