# One team, one plan: building integrated community services around the family

Theme: Integrated Community Services  
Audience: Political + Technical  
Reading time: 10 min read  
Updated: 2026-10-26  
Canonical: https://childguarantee.eu/briefs/integrated-community-services/  
Publisher: UNICEF (Child Guarantee Learning Lab), funded by the European Union

## Summary

Integrated community services replace fragmented provision with one team, one assessment and one plan. The countries that made it work invested for years in the governance behind the services, before or alongside the services themselves.

## In brief

Integrated community services replace fragmented provision, in which a family tells its story at four or five separate offices, with one team, one assessment and one plan. The countries that made it function invested for years in the governance behind the services, before or alongside the services themselves. Finland's integrated service model for all children from birth to age 18 and their families works as a networked set of services operating across multiple sites, with shared management oversight; Italy made families formal members of the team and turned an eleven-year research project into statutory law; Romania built its model on a community team covering social, health and education with a shared digital tool, and moved from a 45-community pilot to national law in six years. Building a collaborative culture is the part that takes longest and meets the most resistance from systems and professionals.

## The trap: symbolic compliance

A family with overlapping needs, say a health concern, a child falling behind at school and a
housing problem, tells its story at four or five different offices, and is visited at home by
professionals who do not know about one another. The National Action Plan names "integrated
services", but nothing has changed in how this family experiences the state. This is the risk
the Recommendation itself carries: because it leaves design to Member States, "integrated
community services" can become a label attached to pre-existing arrangements, with no
substantive change in how services are delivered or experienced.

Three structural reasons keep recurring.

**First, integration lacks a legal or political anchor.** Where integration rests only on a
project or a strategy, it has no stability and no continuity. Each of the successful documented
practices in Member States began with a formal mandate or achieved one during implementation.

**Second, the governance boundary between sectors at management level stays uncrossed.** Health,
education and social protection hold separate budgets, information systems and reporting lines.
Where integration is attempted only among frontline staff, without aligning the managers and
directors who control those systems, professional integration cannot be sustained.

**Third, commitment is shorter than the change requires.** Programmes designed and funded for
one electoral cycle end before integration matures. Scaling typically takes 6 to 11 years,
spanning several electoral cycles. Sustainability needs a political commitment that lasts as
long.

The rest of this brief addresses one question: what does it take to build integration that
families experience in practice, and in what order?

> "The countries and practices that have moved furthest toward genuine integration share a common pattern: they invested over years in the governance architecture that makes integration possible before, or alongside, investing in service design."
>
> (ECG Learning Lab, Integrated Community Services Synthesis Report, 2026)

**Ask your team:** For a family with overlapping needs in our system today, can we name the one person accountable for coordinating across health, education and social services, or do they still tell their story at every entry point?

## Three axes, one case manager, four questions

Integration under the Child Guarantee operates on three axes, and a plan should take all three
into account. **Horizontal integration** is cross-sectoral policymaking at national level, with
a designated lead institution, a formal interministerial agreement, and a shared monitoring
framework holding all ministries to common outcomes. Germany demonstrates this by anchoring its
model in a federal-state administrative agreement that obliges health and child protection
authorities to co-finance and co-plan. **Vertical integration** synchronises national mandates
with regional and municipal delivery. Local and regional authorities carry the largest part of
transposing the provisions into reality, which needs fiscal transfers calibrated to need, shared
standards, and capacity support for weaker municipalities. The Netherlands illustrates this
through national legislation that sets the entitlement framework, while municipalities hold both
the budget and the operational responsibility for youth care. **Operational integration** is the
frontline model families encounter: a single multidisciplinary team, one assessment, one plan,
rather than agencies in sequence. Finland co-locates services under one roof, and Romania's
community team acts as a single point of contact. Where all three align, the plan reaches the
child; where one is missing, it can hold back the other two.

At the centre of every functioning model is case management: a named case manager who
coordinates assessment, planning, delivery, monitoring and review on behalf of a child and
family across sectors, so that families do not navigate fragmented systems alone and no child
falls through the gaps. To show that a practice is integrated, and not only rhetorically
aligned, it should answer four questions: who is the case manager, how is data shared lawfully,
what links the National Action Plan to local delivery, and how is the effect measured?

### Case: Finland: Services under one roof, open to every family

*A mature operational model: co-location plus universal framing.*

Finland's Family Centres co-locate maternity and child-health services, social work and
parenting support under one roof, designed as open meeting places any parent can use. The
universal framing normalises service contact, removes stigma, and lets struggling families seek
help without being labelled. The model was co-designed over roughly a decade of monthly
national-regional meetings, drawing on Sweden, Norway and the Netherlands, and the 2023 Sote
reform created the county-level architecture for permanent integration. Practitioners describe
the shift to "seeing the whole child" as taking close to twenty years.

**What transfers:** universal, open-access framing to reduce stigma and increase reach;
management-level governance as the precondition for frontline integration; adapting an imported
model to your own governance gaps rather than copying its features.

**The catch:** roughly two decades of culture change and eight years of sustained government
funding, until counties and municipalities absorbed the costs. The 2023 reform split social and
health (22 counties) from education (more than 300 municipalities), and there is still no
nationwide evaluation.

### Case: Italy: The family as a member of the team, and a pilot recognised by law

*Turns participation into a formal role and shows the full pilot-to-statute pathway.*

Italy's P.I.P.P.I. programme makes the family a formal member of the multidisciplinary team,
co-authoring its own intervention plan rather than receiving an expert-led one. It is the
methodological innovation with no direct parallel among the documented practices, and one that
the programme's data link to better outcomes. Built on the "World of the Child" assessment
framework and the RPMonline platform, and backed by LabRIEF at the University of Padova, the
programme combines a participatory intervention methodology, a structured multidisciplinary
team model, continuous professional training and a rigorous evaluation framework. Italy spent
eleven years moving from a research project to a statutory Essential Level of Social
Provision: a decade of building political support, generating evidence, training a
professional community, and surviving several changes of government. Reported results include
statistically significant gains across seven cycles and a 2.1% institutionalisation rate.

**What transfers:** family participation operationalised as a formal team member, with the
tools and training to make it count; a shared assessment platform from the start; the
community of practice and university partnership that secure quality; legal embedding.

**The catch:** eleven years and sustained multi-government commitment to reach statutory
status; a patchwork of funding still being made predictable; and strong regional inequality
between north and south, which made legally defined essential levels necessary in the first
place.

### Case: Romania: A multidisciplinary team, a shared tool, and a six-year path to law

*Delivers integration without buildings. The most transferable model for lower-resource and rural contexts.*

Romania's Minimum Package of Services model is built around a community team, typically a
community social worker, a community nurse, and a school counsellor or mediator, which is the
single point of contact for families: joint assessments, shared individual case plans and
shared follow-up. The community teams were backed by county coordinators offering
methodological support and supervision, and their work ran through the digital case-management
tool Aurora. The Bacău pilot across 45 communities over three years reported a 60% reduction in
school drop-out, 50% fewer adolescent mothers, a 40% decrease in unvaccinated children, and
positive movement on 22 of 33 tracked vulnerabilities. It moved from pilot to national law in
six years with all-party support, and is scaling towards 2,000 rural communities.

**What transfers:** integration without co-location, with a small multidisciplinary team as the
point of contact for families; a shared digital case-management tool and a structured training
curriculum; a data-driven risk index for territorial targeting; a documented six-year
pilot-to-law advocacy pathway.

**The catch:** the pilot was UNICEF-led, which secured training and coordination across 45
communities; at a national scale of 2,000 that intensity is hard to reproduce; continuing
community-worker salaries once project funding ends proved difficult; and scale-up through
ESF+ is not the same as continuing the project, since it brings different ownership, incentive
and capacity constraints.

## What makes adoption work

- **Integrate governance at management level before the frontline.** The most common failure is
  investing in multi-professional teams without aligning the managers, directors and ministry
  officials who control budgets and information systems. Frontline integration cannot outlast a
  governance boundary left uncrossed above it.
- **Commit for several electoral cycles.** None of the documented case-study practices reached
  national scale within a single government term. Short-term project funding is structurally
  incompatible with the change integrated community services require.
- **Make family participation real, with method and training.** Real participation of families
  and children needs specific methodological tools, training and accountability on the
  professionals' side. Italy's data show that families who co-author their plans achieve
  significantly better outcomes than those in expert-led models.
- **Design monitoring and data systems from the outset.** The largest systematic gap across the
  29 documented practices is the absence of comparable outcome data. Practices that invested
  early in a shared platform and in validated assessment tools that frontline staff can
  administer can now generate the evidence that sustains political and financial commitment.

**Ask your team:** Have the managers and directors across our sectors agreed how they will share budgets, data and accountability, before we ask frontline staff to work as one team?

## What gets in the way

- **The pilot-to-scale gap.** A model that performs in a well-resourced pilot is not the same at
  national scale. Romania's pilot was UNICEF-led across 45 communities; reproducing it across
  2,000 communities is a more demanding task. Portugal's national coordination team says it would
  slow the rollout if it started again: it prioritised national coverage over depth and, with
  about four staff, cannot fully support the 164 units now in place.
- **Silos persist at the frontline and, more persistently, at leadership level.** Professionals
  are trained to see only their own part of a child's situation; shifting to the whole child is a
  cultural change that took Finland around twenty years and still needs work. Coordination has to
  be built at management level too, not only at the front line.
- **The funding cliff and split employment.** Finland had eight funded years, then counties had
  to absorb the cost. In Romania the community team answers to up to three employers, and the
  poorest municipalities cannot sustain community-worker salaries once project funding ends.
- **Families who are not identified cannot be supported.** Where municipalities lack a
  child-specific social diagnosis, or a lawful basis to share data, the most excluded families
  stay invisible to services. In Portugal, benefits are attributed automatically on the basis of
  tax data, families often do not know they are in the scheme, and only about one in ten responds
  to outreach letters.

## What transfers, and how

**A legal or policy anchor is the strongest predictor of survival.** Legal embedding, whether
recognition in primary legislation or as a statutory service with a budget line, is the single
most powerful predictor of long-term viability, regardless of how good the model is. Every
documented case-study practice began with or achieved a formal mandate.

**Build on existing local infrastructure, not parallel structures.** Portugal reached 129 local
units in under two years by embedding them in the pre-existing CLAS social network. Countries
with local social-planning bodies or family-support networks should activate them rather than
build new institutions, which is slower and more costly.

**A shared digital case-management tool makes integration structural.** Aurora and RPMonline
embed cross-sector coordination in daily practice, so collaboration no longer depends on
individual relationships that dissolve with staff turnover.

**Universal framing reduces stigma and widens reach.** Designing services for all families, not
only vulnerable ones, as Finland's open meeting places and digital family centres do, normalises
service contact and lets struggling families seek help without being labelled.

**Where the nine candidate and potential candidate countries start.** At this stage the main constraint usually lies in the governance boundary between the
social, health and education systems, less in the service model. The starting position
resembles the pilot stage of the documented countries: services delivered by sectors,
integration named in the plan but not yet built into how families experience services, and
no budgetary commitment for integrated services. The transferable first move is to align
managers and directors across sectors and to plan the pilot-to-law pathway.

> "Integrated community services for children are not a technical solution to a service delivery problem. They are a political and governance commitment to the proposition that every child, regardless of where they live, what their family situation is, or what combination of needs they present, should be met by a coherent, coordinated, family-centred response from the state. Making that commitment real, in legislation, in budgets, in professional practice, and in the daily experience of the most vulnerable families in the EU, is the work of the European Child Guarantee."
>
> (ECG Learning Lab, Integrated Community Services Synthesis Report, 2026)

## What transfers

| Component | Transfers | Effort | Note |
|---|---|---|---|
| Legal or political anchor | yes | high | The strongest sustainability lever, but it needs an evidence base, a political window and commitment across electoral cycles: six years in Romania, eleven in Italy. |
| Building on existing local infrastructure | context-dependent | medium | Transfers wherever local social-planning bodies or family-support networks already exist; where they do not, a coordinating structure has to be created first. |
| Shared digital case-management tool | yes | medium | Reference models exist (Aurora, RPMonline), but each country needs a lawful basis for sharing data across sectors and sustained training for practitioners. |
| Universal framing | partial | low | The design principle transfers readily, but fully open services such as Finland's family centres depend on broad universal service coverage already being in place. |

## Applied scenarios

Build the service that families experience as one: Three applied activities from the same evidence base: test two systems against the four questions that separate integration from its label, compare the routes Italy and Portugal took and find what makes integration hold, and lead a pilot through eight years of decisions towards a permanent national service. https://childguarantee.eu/modules/integrated-community-services/

## Sources

- Documenting experiences of the European Child Guarantee: Synthesis Report, Integrated Community Services (2026) (UNICEF. The evidence base behind this brief, covering 29 documented practices. Link pending publication.)
- Summative Evaluation of the Minimum Package of Services https://www.unicef.org/romania/media/866/file/Summative-evaluation-of-the-Minimum-Package-of-Services.pdf (UNICEF Romania, 2019. The independent evaluation of the Bacău pilot.)
- Minimum Package of Services (MPS) Model: A Solution for Ending Child Poverty and Social Exclusion https://www.unicef.org/romania/media/14856/file/MPS%20-%20A%20Solution%20for%20Ending%20Child%20Poverty%20and%20Exclusion.pdf.pdf (UNICEF Romania. The model in brief.)
- P.I.P.P.I. Report conclusivo della settima implementazione (2018-2020) https://www.minori.gov.it/sites/default/files/report_pippi7.pdf (Milani, P. et al., 2020. LabRIEF, Università di Padova. The seventh-cycle results.)
- P.I.P.P.I. Programme of Intervention for Prevention of Institutionalization: capturing the evidence of an innovative programme of family support https://www.researchgate.net/publication/300049476_PIPPI_Programme_of_intervention_for_prevention_of_institutionalization_Capturing_the_evidence_of_an_innovative_programme_of_family_support (Serbati, S., Ius, M. and Milani, P., 2016. The programme's design and evidence, in English.)
- Building Brighter Futures: Implementing the European Child Guarantee in Portugal https://www.oecd.org/en/publications/building-brighter-futures-implementing-the-european-child-guarantee-in-portugal_bbc928ea-en.html (OECD, 2025. The source for the Local Child Guarantee Units.)