Abstract
The progressive aging of the Italian population and the increasing prevalence of multimorbidity and frailty call for a reorganization of health and social care services. In this paper we aim to critically examine Ministerial Decree 77/2022, within Mission 6 of the National Recovery and Resilience Plan, which establishes new models and standards for community-based care and offers an unique opportunity to deliver care that is closer to people's homes, fostering a holistic approach that combines clinical expertise, social support, and technological innovation. The reform places Community Houses and Health Districts at the core of integration between hospitals, general practitioners, and social services. The care of frail older adults relies on population stratification through validated tools, such as the Primary Care Frailty Index (PC-FI), and on the development of individualized care plans that integrate multidisciplinary interventions. Although general practitioners remain central in the health care system, geriatricians may play a pivotal role in multidimensional assessment, pharmacological management, health promotion, and the coordination of care teams. Telemedicine and digital tools support continuity of care and ensure traceability of clinical processes. Indicators of accessibility, equity, appropriateness, acceptability, and effectiveness are proposed, including the use of Patient-Reported Outcome and Experience Measures proposed for the evaluation of its impact. The reform's success will depend on overcoming methodological and operational barriers, reducing regional disparities, and ensuring that clinical expertise, social support, and technological innovation deliver measurable benefits for frail older adults.