An older person living with diabetes, reduced mobility and emerging cognitive impairment may encounter several parts of Türkiye's health and social-support system within a few months. A family physician manages chronic disease. A hospital treats an acute episode. Home health may become involved after discharge. The family investigates social assistance or home-care support. A municipality may provide community services. If dependency increases further, residential care may eventually be considered.
Each service can perform its own role competently while the person and family still experience the overall pathway as fragmented. That distinction sits at the centre of care coordination. Across the Türkiye Aging, Long-Term Care & Community Support Knowledge Hub, health care, long-term support, disability services, family caregiving and municipal provision repeatedly intersect. The practical challenge is ensuring that people do not have to reconstruct those connections themselves every time their circumstances change.
This matters increasingly as Türkiye ages. Long-term care needs are becoming more complex, while responsibility remains distributed across the Ministry of Health, the Ministry of Family and Social Services, provincial structures, municipalities, public and private providers, civil-society organisations and families. Türkiye's Twelfth Development Plan calls for stronger connections between social services and assistance, diversification of service models and a care model combining health and social services for older people. A March 2026 cooperation protocol between the two principal ministries also created a practical new connection by enabling access to social-service personnel through selected Healthy Life Centres.
The opportunity is not simply to add a coordinator to every pathway. It is to create a system in which responsibility for connecting care becomes explicit rather than accidental.
Fragmentation is different from service diversity
A long-term-care system does not need one organisation to provide everything. Older and disabled people often benefit from specialist organisations with different expertise. Health professionals, social workers, rehabilitation teams, municipalities, residential services and community organisations legitimately perform different functions.
The problem begins when those differences become disconnected pathways.
WHO's assessment of integrated long-term care in Türkiye identified fragmented governance, financing and service delivery, different entry points for home-based health and social care, and an absence of standardised needs-assessment procedures or clearly defined long-term-care pathways. It also found that coordination between professionals at service level could sometimes be stronger than coordination between organisations and governance structures.
That observation remains important because it distinguishes structural fragmentation from poor professional commitment. A family physician may recognise a social problem but lack a simple route for connecting the person with appropriate support. A social worker may understand that deteriorating health is making an existing care arrangement unsafe but depend on separate health processes to respond. Municipal teams may know a household well without their information being visible elsewhere.
Stronger coordination across health and social care therefore does not require every organisation to become identical. It requires clearer interfaces between them.
Türkiye's long-term-care pathway has several legitimate entry points
People do not enter long-term support through one door.
An older person may first become visible through a Family Health Centre because of chronic disease or falls. Another may come to attention after hospital admission. A family may approach the Ministry of Family and Social Services about Home Care Assistance or residential provision. A municipality may identify somebody through a home-support programme. A disabled person may already be known to social services for many years before ageing creates additional health needs.
This plurality has advantages. People can be identified in the settings they already use.
It also creates an operational question: what happens after the first organisation identifies a need that it cannot itself meet?
A mature pathway needs more than a telephone number for another service. It needs a reliable process through which the receiving service understands why the referral has been made, assesses the request, communicates the outcome and ensures that urgent needs do not disappear between organisational boundaries.
This is the principle behind closed-loop referral and follow-up. The concept does not require Türkiye to adopt another country's administrative model. It simply means that a referral should have an observable outcome rather than ending when one organisation sends information elsewhere.
For a person and family, that changes the experience from "we told you who to contact" to "we have connected you with the next part of the pathway and know what happened."
Case management needs a clear purpose before it becomes a new role
The term case management is used differently across countries and sectors. Importing a standard international model into Türkiye would risk adding another layer to an already distributed system.
The more useful question is which coordination functions need to exist.
For people with relatively straightforward needs, effective referral and information exchange may be enough. They should not require a permanent coordinator simply because two services are involved.
More complex situations can require something stronger. Someone living with frailty, dementia, multiple chronic conditions, functional dependency and limited family support may have several simultaneous interventions. Without an identified professional or team maintaining an overview, each service can optimise its own component while nobody monitors whether the overall arrangement remains workable.
Case-management functions can include:
- developing a whole-person understanding of health, functional and social needs;
- identifying which organisations are involved and clarifying their responsibilities;
- connecting referrals and following unresolved actions;
- ensuring that the person and family understand the plan;
- recognising changes that require reassessment or escalation;
- coordinating reviews when several services need to change together; and
- maintaining continuity during transitions between settings.
Those functions could sit with different professionals according to the person's principal needs and local service architecture. The central requirement is that responsibility is explicit.
Türkiye therefore does not necessarily need a single national profession called the long-term-care case manager. It needs reliable coordination capability proportionate to complexity.
Operational scenario: several services, but nobody holds the whole picture
An 82-year-old woman in İzmir lives with her husband, who is 85. She has heart failure, arthritis and increasing difficulty bathing and preparing meals. Her husband manages most household tasks but has begun experiencing his own mobility problems.
After an episode of breathlessness, she is admitted to hospital. Clinical treatment is successful and she returns home. The hospital provides discharge information, her family physician resumes chronic-disease follow-up and home health becomes relevant to her continuing medical needs. Her daughter, who lives elsewhere in the city, begins investigating social support because the couple are increasingly struggling at home.
Each part of the response is reasonable. The coordination risk lies between them.
The family physician may not know how difficult bathing has become. The social assessment may not fully capture the recent clinical deterioration. Home-health professionals may identify caregiver strain during a visit without knowing whether a social-service application has progressed. The daughter becomes the person carrying information between systems.
A coordinated pathway would establish who is maintaining the overview. The couple's functional ability, health needs, home circumstances and family capacity would be considered together. Referrals would have identified outcomes, and a significant deterioration observed by one service would trigger communication with the others rather than simply being recorded locally.
The objective is not a large multidisciplinary meeting after every contact. It is proportionate coordination that prevents several valid interventions from becoming an incoherent care arrangement.
Assessment is the foundation of coordination
Coordination cannot compensate indefinitely for incompatible assessments.
Different organisations need different information. A physician assesses clinical conditions. Social services consider care and support needs and eligibility. A rehabilitation professional examines function. A residential provider assesses whether it can safely meet the person's needs. Those distinctions should remain.
Problems arise when no part of the system brings those perspectives together.
WHO's work on Türkiye has highlighted the lack of standardised needs assessment across long-term care. This does not necessarily mean every organisation should use one identical form. A more realistic objective is a common core understanding of the person that can travel across the pathway.
That core might include functional ability, cognition and communication, major health conditions, medication, living arrangements, caregiver availability, current services, significant risks and the person's own priorities.
The information required should remain proportionate. A coordination system that demands extensive duplicate assessment can increase workload while making care less responsive.
The stronger principle is "collect for a purpose and reuse where appropriate." Information already established by one service should not automatically have to be reconstructed by another, provided that sharing is lawful, accurate, necessary and appropriately governed.
The 2026 health and social-services protocol creates a practical coordination opportunity
Türkiye's March 2026 cooperation protocol between the Ministry of Health and the Ministry of Family and Social Services is important because it moves coordination closer to the point where citizens already seek help.
Under the initial implementation, social-service personnel are to work within primary-care settings in 72 districts across 34 provinces where a Social Service Centre or liaison unit is not present. Healthy Life Centres can therefore become a route through which people access social support alongside preventive and community health services.
This should be understood as an emerging coordination mechanism rather than evidence that health and social care are now fully integrated nationally.
Its potential lies in reducing distance between identification and response.
An older person attending a Healthy Life Centre may disclose that a spouse can no longer provide care. A clinician may identify housing or financial circumstances affecting health. Social-service personnel can become accessible without requiring the person to understand another institutional pathway first.
The next operational question is whether co-location produces genuinely connected work.
Putting professionals in the same building helps, but coordination depends on referral processes, communication, role clarity and follow-up. If health and social-service records remain entirely separate and neither side can see whether an action was completed, proximity alone will not close the pathway.
Organizations examining comparable interfaces can use the Governance Maturity Assessment to structure questions about responsibility, escalation and oversight. It does not evaluate compliance with Turkish arrangements, but it can help distinguish informal professional cooperation from coordination that is supported by accountable operating systems.
Coordination should reduce the navigation burden on families
Families are major coordinators of care in Türkiye.
They book appointments, communicate with different services, monitor medication, arrange transport, submit applications, interpret professional advice and notice deterioration. This knowledge can make family members essential partners.
It can also conceal weaknesses in the formal pathway.
A system may appear coordinated because a daughter carries hospital information to a family physician, telephones social services repeatedly and ensures that separate professionals know what the others have said. The services are connected, but the connection depends on unpaid labour.
Care coordination should therefore complement family involvement rather than simply formalise reliance upon it.
Families need to know:
- which service is responsible for which part of support;
- who to contact when circumstances change;
- whether a referral or application has been received;
- what happens while a decision is pending; and
- when a problem requires health, social-service or emergency escalation.
People without strong family networks need particular attention. Navigation systems that assume an available, confident relative can create significant inequality for people living alone, people whose children live elsewhere and households where the caregiver has their own health or communication needs.
This connects coordination with wider caregiver support and family navigation. The strongest pathways use family knowledge while ensuring that system continuity does not depend entirely upon it.
Transitions reveal whether coordination is real
Coordination is easiest to describe when somebody remains within one service. Its quality becomes visible when responsibility changes.
Hospital discharge is one obvious transition, but long-term care contains many others: deterioration from independent living to home support, movement into residential care, return home after rehabilitation, progression of dementia, loss of a family caregiver or transfer between facilities.
Each transition changes who knows the person and who holds responsibility.
The previous article in this series examined hospital discharge specifically. The broader case-management issue is what happens to continuity after any transfer.
A strong transition should carry forward the person's current needs, medication where relevant, risks, preferences, existing support, family circumstances and unresolved actions. The receiving service should know not only what has happened but what it is expected to do next.
For complex cases, an identified coordinating professional can provide continuity while individual providers change.
That does not mean one professional controls every decision. Clinical decisions remain with appropriate health professionals; social-service eligibility remains within the relevant administrative framework; residential organisations remain accountable for the support they provide. Coordination connects responsibility without erasing it.
Operational scenario: dementia turns several small gaps into one large risk
A 77-year-old man in Ankara has moderate dementia and hypertension. He lives with his wife, who has managed most of his support but becomes unwell and requires hospital treatment herself. Their son lives in another province.
No single new problem initially appears overwhelming. The man still walks independently. Food is available. Medication has been prescribed. Neighbours occasionally check on him.
The risk emerges from the combination.
His medication routine becomes unreliable, he misses a health appointment and neighbours report that he has been leaving home at unusual times. His son contacts several services but is uncertain which one should coordinate the response.
A stronger pathway would recognise the sudden loss of the caregiver as a material change in the man's care system, not simply a family event. Health needs, cognition, immediate safety, social support and temporary care options would be considered together. Responsibility for follow-up would be identified until a sustainable arrangement was established.
If his wife returned home quickly, support could then be reviewed rather than automatically maintained at crisis intensity. If she could no longer provide previous levels of care, the pathway would move into a fuller reassessment.
The lesson is that complexity often arises from interaction between needs rather than the severity of one diagnosis. Case management adds value when it can see those interactions early enough to prevent avoidable crisis.
Information sharing should support coordination without creating unrestricted access
Better coordination is often described as a data problem. It is partly one.
Türkiye has substantial digital health infrastructure, but long-term care extends beyond the health system. Social-service records, municipal services, private provision and family knowledge do not automatically form one information environment.
The objective should not be to give every organisation access to every piece of information.
Different professionals need different information, and privacy remains important. A social-support provider may need to understand functional limitations and emergency risks without receiving an individual's complete medical history. A hospital may need to know that somebody lives alone and receives home support without accessing unrelated social information.
Effective interoperability and data-exchange workflows therefore depend on purpose, permissions and accountability as much as technology.
At a minimum, coordination benefits when services can establish whether another organisation is involved, who the relevant contact is, what action has been requested and whether that action has been completed.
This creates an important distinction between a shared record and shared situational awareness. Türkiye may be able to strengthen the latter substantially even where legal, technical or organisational conditions do not support a fully unified record.
Digital development should also reduce duplication rather than create additional administrative work. If professionals must record the same coordination activity in several disconnected systems, technology can increase rather than reduce workload.
The Digital Transformation, AI and Cybersecurity Readiness Assessment offers organisations a way to examine similar questions about information architecture, workforce readiness, governance and digital risk. It is not a Turkish interoperability standard, but its broader readiness framework can help ensure that coordination technology is designed around operational need rather than technology acquisition alone.
Local coordination needs enough flexibility to reflect different communities
Türkiye's long-term-care environment is not uniform. Large metropolitan municipalities may have different community-service capacity from smaller municipalities. Rural populations face distance and transport barriers that are less prominent in major cities. Availability of public, private and civil-society provision also varies.
National policy therefore needs to establish expectations for continuity without assuming that every locality will use an identical operating model.
The Ministry of Family and Social Services' 2026 organisational arrangements illustrate the breadth of actors relevant to older people's support. The General Directorate of Services for Persons with Disabilities and the Elderly has responsibilities covering community-based care, home social services, active-living services, residential older-person care, private facilities and coordination with local authorities, universities, civil-society organisations and the private sector.
YADES, the Programme for Supporting the Elderly, adds another local dimension by providing national financial support for municipal projects intended to help older people remain within their social environment.
These arrangements create opportunities for locally responsive support. They also increase the importance of knowing what exists in each locality.
A national coordination strategy therefore needs a local service map. Professionals cannot navigate people towards services that are invisible to them.
This is particularly relevant to rural and underserved communities, where coordination can partly compensate for scarcity by making better use of limited capacity, but cannot create services that do not exist.
Persistent referral failure should therefore become planning evidence. If professionals repeatedly identify a need but have nowhere appropriate to refer people, the issue has moved beyond individual case management into service development.
Operational scenario: coordination across a municipality, health services and family support
A municipality participating in an older-person support programme identifies an 80-year-old man living alone in a district outside a major metropolitan centre. Staff initially become involved because he needs practical assistance at home. During visits they notice increasing breathlessness, weight loss and difficulty remembering appointments.
The municipal team cannot diagnose or treat those problems, but it has valuable observational information. A fragmented response would simply advise him to contact health services.
A coordinated response connects him with the appropriate primary-care route and makes the reason for concern clear. Health assessment identifies a chronic condition requiring treatment. At the same time, his functional difficulties are reviewed because clinical treatment alone will not resolve his difficulty managing the home.
His niece lives forty kilometres away and wants to help but cannot visit daily. She is involved with his agreement, and the plan defines what support she can realistically provide rather than assuming availability.
Follow-up then needs to confirm that each part of the arrangement is working. If the municipal service observes continuing deterioration, it has an understood escalation route. If health professionals identify increasing dependency, they know how to reconnect with social support.
The key asset is not a single coordinator with authority over every organisation. It is a shared operating expectation that identified needs cross organisational boundaries with the person rather than being left behind at each boundary.
Complexity should determine coordination intensity
One risk in building a more coordinated system is over-engineering routine care.
Not everybody needs multidisciplinary case management. Requiring extensive coordination processes for straightforward needs can consume professional time and create waiting lists for people who genuinely need intensive support.
A more sustainable model stratifies coordination according to complexity.
Someone with stable chronic disease, strong family support and one social-service need may require a reliable referral and clear information. A person with multiple conditions, frequent hospital use, dementia, functional decline and caregiver breakdown may need active case management, planned multidisciplinary review and close follow-up.
Complexity is not the same as diagnosis count.
Relevant factors can include rapid change, cognitive impairment, unstable health, multiple providers, medication complexity, safeguarding concerns, living alone, caregiver fragility, repeated transitions and previous failure to engage successfully with services.
This makes triage important. Coordination resources should be directed towards situations where disconnected care creates the greatest risk or burden.
The principle also supports de-escalation. Intensive case management should not become permanent simply because somebody once experienced a crisis. When needs stabilise, responsibility can return to routine services with clear re-entry criteria if circumstances deteriorate.
Workforce capability matters more than creating coordination titles
Coordination is a workforce function before it is a job title.
Family physicians, nurses, social workers, rehabilitation professionals, residential staff and municipal teams all need enough understanding of the wider system to recognise when another service should become involved.
They also need communication skills and professional confidence to challenge unclear responsibility.
A referral that repeatedly returns because two organisations disagree about responsibility is not merely an administrative inconvenience. For the person waiting, it may mean worsening dependency, caregiver exhaustion or an avoidable hospital admission.
Workforce development should therefore include navigation, multidisciplinary communication, escalation and understanding of organisational boundaries alongside discipline-specific competence.
Supervision is equally important. Frontline professionals need somewhere to escalate situations in which the correct pathway is unclear. Otherwise experienced staff develop informal workarounds while less experienced staff follow organisational boundaries rigidly.
This connects coordination with workforce capability and skill mix. The system does not necessarily need every worker to become a case manager. It needs workers who understand their own role, recognise the limits of it and can connect effectively with others.
Operational scenario: complexity requires a named coordinating function
A 72-year-old woman in Gaziantep has diabetes, chronic kidney disease, reduced mobility and depression. Her husband provides most daily support but is becoming exhausted. During six months she has several hospital contacts, misses outpatient appointments and experiences two falls at home.
Individually, each issue has an obvious service response. Together, they indicate that the current arrangement is unstable.
At this level of complexity, simply sending additional referrals may add more professionals without improving continuity. A named coordinating function becomes valuable.
The coordinating professional or team establishes the current services, identifies unresolved needs and agrees with the woman and her husband which problems require priority. Clinical responsibilities remain with the appropriate health professionals. Social-service decisions remain within their own framework. The coordinator's role is to ensure that those actions form one workable plan and that deterioration is visible across the pathway.
Her husband's capacity is considered explicitly because caregiver exhaustion is part of the risk picture. Falls are examined alongside medication, mobility and the home environment rather than treated as isolated incidents. Missed appointments are explored to understand whether transport, depression, communication or competing care demands are responsible.
If stability improves, coordination intensity reduces. If hospital use and falls continue, the repeated pattern becomes evidence that the plan requires redesign rather than simply another referral.
This is the point at which case management provides most value: not by taking ownership away from individual services, but by maintaining accountability for the connections between them.
Funding can either support or undermine coordination
Care coordination has financial consequences even when it does not create a new service.
Professionals need time to communicate. Organisations need information infrastructure. Complex cases may require joint review. Community alternatives need enough capacity to receive referrals. If payment or budgeting arrangements recognise only direct service activity, coordination can become invisible work.
Türkiye's long-term-care financing remains distributed across health-system funding, social assistance, Ministry provision, municipal activity, private purchasing and extensive family care. The Twelfth Development Plan also includes the development of elderly-care insurance as a policy objective, rather than an already established national entitlement.
Future financing reform therefore offers an opportunity to consider continuity alongside coverage.
A new funding mechanism would not automatically integrate services. Separate providers can remain fragmented even when they receive money from the same source. Conversely, coordination can improve without complete financial integration if responsibilities, referral pathways and incentives are aligned.
The key question is whether financial arrangements make organisations responsible only for their own activity or encourage them to consider what happens to the person before and after that activity.
Where fragmented pathways create repeated assessment, avoidable hospital use or premature reliance on residential care, better coordination may also have economic value. Those effects need evidence rather than assumption, but they are relevant to the wider impact of care on system capacity and flow.
Coordination quality needs to be measured through completed pathways
Counting referrals is a weak measure of coordination.
A service can make hundreds of referrals without knowing whether anybody received help. Meeting frequency is similarly limited: multidisciplinary meetings demonstrate activity, not necessarily continuity.
Stronger measures examine what happened across the pathway.
Useful indicators might include the proportion of priority referrals acknowledged and completed, time from identified need to response, repeated assessments, unresolved actions, unplanned transitions, avoidable duplication and whether people know who to contact when needs change.
For higher-complexity groups, services can also examine whether coordinated plans are reducing repeated crisis use, maintaining people safely in preferred settings or improving functional and caregiver outcomes.
Qualitative evidence matters too. People and families can identify fragmentation that administrative systems fail to detect. Repeatedly hearing "nobody knew what the other service was doing" should be treated as system intelligence.
The Quality Dashboard Builder can help organisations structure comparable pathway indicators and combine operational measures with outcomes. It is not a national Turkish reporting framework, but it illustrates how coordination can be measured as a process with observable results rather than an aspiration.
Governance needs to see the gaps between organisations
Most organisations govern what happens inside their own boundaries more easily than what happens between them.
A hospital can monitor discharge procedures. A residential facility can review care plans. A municipality can monitor delivery of its own support. A social-service organisation can track applications.
The most important coordination failures may sit between those datasets.
Governance therefore needs pathway-level visibility.
If one locality experiences repeated failed referrals between health and social services, the pattern should reach decision-makers able to change the interface. If people are repeatedly discharged from hospital before community support is ready, the issue needs joint examination. If the same information is collected repeatedly because systems cannot exchange it, digital and governance leaders need to see the operational cost.
This connects care coordination with system integration and multi-agency working. Partnership becomes meaningful when organisations accept some responsibility for the quality of the interface, not only the quality of their own component.
National governance has a role in defining expectations and reducing unnecessary variation. Provincial and local structures need enough authority to solve practical pathway problems. Providers need clear escalation arrangements. People using services and families need routes through which repeated navigation problems influence improvement.
Persistent fragmentation should therefore be treated as a governance signal, not simply an unfortunate characteristic of a complex system.
Türkiye can build coordination around existing infrastructure
The strongest opportunity may be to strengthen connections that already exist rather than create an entirely new parallel structure.
Family Health Centres provide established local health relationships. Healthy Life Centres offer multidisciplinary preventive and community health services and, under the 2026 cooperation protocol, are beginning to provide a closer interface with social services in selected districts. Social Service Centres and Ministry provincial structures already connect people with social-support pathways. Municipalities contribute local services and YADES projects. Hospitals, home health and residential organisations provide further points from which changing needs can be identified.
A more coordinated system can build on those assets by making several operating expectations increasingly consistent:
- people should have a clear route into support regardless of where need is first identified;
- referrals involving significant need should have a visible outcome;
- complex cases should have an identified coordinating function;
- transitions should transfer responsibility and essential information explicitly;
- families should participate without becoming the default information system;
- recurring pathway gaps should generate management and policy action; and
- coordination intensity should increase or reduce as complexity changes.
These principles do not require every province or municipality to deliver identical services. They create a common expectation about continuity while allowing local implementation to reflect available infrastructure.
International learning lies in continuity, not a particular case-management model
Internationally, long-term-care systems use many mechanisms to coordinate complex support. Some rely on care managers, others on multidisciplinary primary-care teams, municipal assessors, insurers or integrated health and social-care organisations.
Those structures reflect different legislation, funding arrangements and administrative traditions. Türkiye cannot simply import one of them.
The transferable lesson lies in the functions underneath the structure.
Someone needs to recognise complexity. Responsibility needs to be clear. Referrals need to close. Essential information needs to travel. Transitions need active handover. People and families need to know who is coordinating the overall arrangement. Repeated failures need to reach decision-makers.
Türkiye's own policy direction already points towards stronger institutional coordination. The Twelfth Development Plan seeks better linkage between social services and assistance and a combined health and social-services model for elderly care. The 2026 inter-ministerial protocol provides a practical example of bringing social-service access closer to primary and preventive health infrastructure. The General Directorate's current organisational responsibilities also explicitly include coordination across public bodies, local authorities, universities, civil society and private organisations in older-person services.
The next step is to turn those connections into pathways that remain coherent from the citizen's perspective.
Conclusion
Care coordination in Türkiye is not primarily about creating another administrative layer around older and disabled people. It is about making responsibility for continuity visible across a system in which health care, social services, municipalities, providers and families legitimately perform different roles.
The country's current direction provides useful foundations. National planning recognises the need for stronger integration, community and home-based support are developing, and the 2026 cooperation between the Ministry of Health and the Ministry of Family and Social Services creates new local interfaces. Yet coordination will ultimately be judged through operational experience: whether a referral reaches its destination, whether changing needs trigger reassessment, whether transitions transfer responsibility clearly and whether somebody maintains an overview when complexity becomes too great for separate services to manage independently.
Türkiye does not need every person receiving long-term support to have a permanent case manager. It needs proportionate coordination: simple navigation where needs are straightforward, active case management where several risks and services interact, and clear routes for increasing or reducing that intensity over time.
The strategic opportunity is to make fragmentation measurable and therefore manageable. When pathway gaps, unresolved referrals, repeated assessments and family navigation burdens become visible to governance, individual coordination problems can inform wider service redesign. That is how separate organisations begin to operate as a more coherent long-term-care system without losing the specialist roles that make each of them valuable.