Transitioning from episodic and fragmented health care to a comprehensive care delivery model requires a deep organizational restructuring. With the publication of the technical guidelines “Multidisciplinary and Multiprofessional Teams in Community Houses,” the National Agency for Regional Health Services – AGENAS, provides operational guidance to translate into practice one of the pillars of the territorial health reform outlined by Ministerial Decree 77/2022 and supported by NRRP funding.
The primary objective of the document is to guide Regions and Health Authorities away from the single-practice model, the isolated work of a single professional, toward an integrated and interprofessional model, capable of addressing demographic aging, the rise of chronic conditions, and the complexity of social-health needs.
A Flexible Model with Variable Geometry
The Guidelines clarify that the Community House team is not a rigid body, but a flexible organization oriented toward the specific needs of the beneficiary. The organizational framework rests on two main levels:
- Basic Team (Essential Core): represents the minimum and stable response for care continuity. It includes the General Practitioner (GP) or Pediatrician of Choice (POC), the Nurse (including the Family and Community Nurse – FCN), the Social Worker, and administrative support staff.
- Expanded Team: progressively engages outpatient specialists (cardiologists, diabetologists, pulmonologists, etc.), Community Medicine and Primary Care physicians, rehabilitation and prevention professionals, mental health specialists, midwives, dietitians, public-health system pharmacists, and the palliative care specialist.
To this system, there is a two-dimensional leadership model: a vertical and structural leadership, guided by the District/Manager of the Community House for overall governance, and a horizontal and shared leadership, distributed dynamically among team members based on the patient’s prevailing need (the case management function).
The Four Care Pathways and the Operating Phases of Teamwork
The citizen-facing response develops through four fundamental operating phases: identifying the need, multiprofessional analysis and assessment, coordinated execution of interventions, and subsequent follow-up.
The team’s operations are directed toward four specific care targets.
The first domain concerns the management of a point-in-time need or minor acute illness. The team operates through joint or dedicated interventions by physicians and nurses, or via One-Stop Access Points (OSAPs) for problems that are predominantly social. The expected outputs include the immediate issuance of reports, the performance of first-line diagnostic procedures, and the rapid resolution of the clinical or care question.
The second pathway is dedicated to chronic disease in a programmed follow-up. The team ensures proactive care built around the diagnostic-therapeutic care pathways (PDTA), using shared schedules among GPs, pediatricians, specialists, and nurses functioning as case managers. The tangible outcomes of this integrated work include personalized monitoring plans, support for treatment adherence, and training of patients or caregivers in self-management of the condition.
The third target addresses prevention and health promotion. In this context, the Community House board and prevention-focused professionals actively engage to identify healthy individuals or those at risk. Concrete activities translate into organized walking groups, centers for smoking cessation, and programs dedicated to health education and promoting healthy lifestyles.
Finally, the fourth area focuses on frailty and dependence. In this pathway, the team conducts a thorough collegial assessment via the Multidimensional Evaluation Unit, building an operational bridge between the health component and social services. The outcome is the drafting of the Individualized Care Plan (ICP) and its integration with Integrated Home Care (IHC) and the network of local social services.
Enabling Tools and the Participation Pathway
To operationalize the integrated work, AGENAS emphasizes the importance of digital tools such as the Electronic Health Record (EHR), the shared health-and-social care record, and telemedicine platforms. This is complemented by the use of standardized languages and coding schemes (ICPC, ICF, NANDA) and ongoing on-the-job training, essential to ensure real continuity of care.
The AGENAS document is the result of the work of a multidisciplinary panel refined through a public consultation that gathered more than 760 contributions. As highlighted by AGENAS Director-General Angelo Tanese, these Guidelines are not an isolated intervention, “but a building block of a broader strategy through which the Agency accompanies the Regions in transforming Italy’s National Health Service.” The goal is to ensure that reforms translate into concrete organizational models capable of improving the quality of care and people’s lives. The development of Community Houses under DM 77, NRRP investments, management of waiting lists, and strengthening of territorial care are not separate interventions, but parts of a single path of NHS innovation. A more interconnected health system that coordinates data, skills, and organization to support decisions, integrate care pathways, and offer citizens services that are increasingly effective and closer to their needs.”
Subscribe to Integrated Medicine
