Improving patient care pathways between hospitals and communities: The case of COTs

The study focuses on the different COT models emerging across Italy’s healthcare providers, the main challenges that are coming up, and the tactics being used to tackle them.

Specifically, the research seeks to answer the following questions:

• What COT models are appearing in healthcare organizations?
• What are the main barriers to implementation?
• What strategies are being adopted to make COTs operational?
• What regional differences are surfacing in how COTs are being implemented?

Introducing COTs is a paradigmatic example of organizational change, often slowed by resistance and inertia.

The research team used a mixed-methods approach, combining surveys and focus groups with healthcare professionals (nurses, physicians, and administrators) involved in COT implementation at the local level. The sample included 24 healthcare organizations from 12 regions across Italy; the team gathered data on organizational models, operational functions, and the relative challenges.

The 2024 OASI Report observes that COT implementation is following diverse models. While 67% of organizations have adopted a dual-level model (both district and corporate level), 33% use a single-level model (district only).

This choice often reflects prior experience: 63% of the dual-level COTs were implemented by organizations that previously rolled out similar initiatives. In 71% of the cases, COTs also onboard other professionals, such as social workers, physicians, and physiotherapists, especially in contexts where there was prior experience.

The most frequently cited obstacles to implementation include unclear internal processes, resistance to change, and shortages of essential personnel (especially nurses and administrative support staff). Additional issues include misalignment between new models and existing practices and poor interoperability between different healthcare IT systems.

Some regions had already piloted models similar to COTs, which facilitated implementation, while others started from a less structured baseline.

Healthcare organizations are adopting two main approaches to overcoming existing barriers:

• Structural interventions (“fixing”): improving logistics, implementing integrated digital tools, and hiring dedicated staff.
• Cultural and organizational interventions (“framing”): training professionals, actively involving stakeholders, and securing strong support from strategic leadership to overcome internal resistance.

In many cases, organizations are adapting the COT model to their specific context or working to clarify its role and contribution within the broader system.

COTs are not entirely new. Regions such as Veneto and Tuscany have already been testing similar models, albeit under different labels and organizational setups. Thanks to Decree 77 and PNRR funding, we are now witnessing a form of evolutionary convergence, with models becoming more similar across regions. Still, our findings underscore that there is no one-size-fits-all solution. Tailored strategies are essential, shaped by the specific needs each COT aims to address, the organizational culture, and the resources that are available.

While the PNRR is funding the necessary infrastructure, a key question remains: What will the scope of COT activities be? As demand grows in complexity and volume, it will likely become necessary to prioritize target populations for these services.

Ultimately, the system must begin to reconnect the dots between various initiatives, such as COTs and community health centers, and clearly define the health outcomes it aims to achieve. In other words, it’s time for us to ask  broader questions about the system - specifically about the overall purpose of the redesign prompted by the PNRR and Decree 77 - and to start formulating some concrete answers.

Gianmario Cinelli, Federica Dalponte, Lucia Ferrara, Valeria Tozzi, Angelica Zazzera, “Gestire il cambiamento al tempo del PNRRe del DM77: il caso delle COT,” in Rapporto OASI 2024, pp. 421-446.

Read other articles in the OASI Report 2024 series:

• Ricci and Longo - Tell me the truth about the Italian NHS: Four steps toward sustainable universality.
• Broccolo, Guerra, Longo, & Zazzera - The digital revolution of general practitioners and their patients.
• Bobini, Compagni, & Rotolo - Sustainability in healthcare: A new model for the future
• Boscolo, Cinelli, Guerra Petracca, Petralia, Pinelli - If not now, when? The National Recovery and Resilience Plan and the digitalization of the Italian NHS.