An older Brazilian leaves hospital after a fall. Her fracture has been treated, but she is weaker than before admission. She lives alone, struggles to prepare food and has become frightened of bathing without help. Her Unidade Básica de Saúde can manage medicines and rehabilitation needs. CRAS may understand the household's social vulnerability. Her daughter, who lives across the city, is trying to coordinate everything while continuing to work.
None of those actors is necessarily doing the wrong thing. The risk lies in what happens between them. Brazil's long-term care challenge increasingly sits at the interface between the Sistema Único de Saúde (SUS), the Sistema Único de Assistência Social (SUAS), families and a developing network of community and home-based support. The wider Brazil Aging, Long-Term Care & Community Support Knowledge Hub reflects how important those connections are becoming as population aging accelerates.
Brazil does not need to merge SUS and SUAS into one institution to improve integration. The systems exist for different purposes, have different professional roles and are governed through distinct policy and financing arrangements. The stronger objective is to make those differences workable from the perspective of the person: clear referral routes, enough information to coordinate safely, agreed responsibilities, timely escalation and local governance capable of seeing when people repeatedly fall into gaps.
The National Care Policy and Plano Nacional de Cuidados Brasil que Cuida have made this agenda more explicit. Their emphasis on intersectoral action, territorial implementation and social co-responsibility creates a policy framework within which health, social assistance and wider care can become more coherent. Current developments also include local and pilot models specifically testing stronger integration between the two systems. The opportunity is significant, but it remains an implementation challenge rather than an accomplished national reality.
Integration starts by respecting what SUS and SUAS are for
Integrated care is sometimes described as though good systems should erase institutional boundaries. In Brazil, that would be neither realistic nor necessarily desirable.
SUS is the country's universal health system. It provides prevention, primary healthcare, specialist care, rehabilitation, medicines, hospital services, home healthcare and other health interventions.
SUAS is the national social-assistance system. It organizes preventive and specialist social protection through services including CRAS, CREAS, PAIF, PAEFI, community provision, home-based social protection and defined residential or day-service responses.
The same older person may require both systems. A woman with heart failure and declining mobility may need clinical monitoring through SUS while SUAS addresses isolation, financial vulnerability or family strain. A person experiencing abuse may require specialist protection through CREAS while continuing to need healthcare for dementia or frailty.
Integration therefore means coordinated difference rather than institutional sameness.
The wider health and social care coordination agenda is particularly relevant. The central operational question is whether each system recognizes when another type of intervention is required and whether the person reaches it without having to become their own navigator.
Brazil already has the territorial infrastructure needed for integration
One of Brazil's advantages is that neither health nor social assistance starts from a completely centralized model detached from communities.
Primary healthcare, including Family Health teams and community health workers, operates territorially. SUAS similarly uses territorial infrastructure such as CRAS, while CREAS provides specialist protection across defined areas.
This means the systems often work with the same households and communities even though their information, funding and professional structures differ.
A community health worker may know that an older resident repeatedly misses consultations. CRAS may know that the same household is experiencing food insecurity. A rehabilitation professional may know that mobility is worsening, while a daughter quietly compensates by providing increasing amounts of unpaid care.
The information needed to understand the situation therefore already exists in fragments.
The integration challenge is to convert those fragments into proportionate action without creating unnecessary bureaucracy or unrestricted sharing of personal information.
This makes municipal capability especially important. Local systems need enough strategic visibility to understand which interfaces function well and where responsibility repeatedly becomes unclear.
Functional need creates a natural bridge between the systems
Diagnosis alone does not determine whether an older person can manage everyday life. Function is therefore one of the most useful concepts for connecting health and social care.
Someone may have stable chronic disease but struggle to bathe, cook or leave home. Another person may have several diagnoses but remain independent. Functional assessment helps services understand the practical consequences of health conditions rather than relying on disease labels.
Brazil's growing use of multidimensional assessment and the IVCF-20 — Índice de Vulnerabilidade Clínico-Funcional-20 — within primary healthcare creates an important opportunity. Ministry of Health guidance also recognizes the instrument's relevance beyond health, including use by SUAS professionals.
A shared concept of clinical-functional vulnerability does not mean that a social worker and physician perform the same assessment for the same purpose. It means both can understand that a change in mobility, cognition or daily function may require action across systems.
The stronger pathway therefore moves from identification to response. A high level of vulnerability should not simply generate another score. It should help teams decide whether the person requires closer health monitoring, rehabilitation, family support, social-assistance intervention or some combination.
That places functional assessment within the wider disability and functional-need agenda rather than treating it solely as a clinical measure.
Operational scenario: one assessment reveals three different problems
An 80-year-old man attends primary healthcare because his daughter is worried about increasing confusion. The clinical review finds no immediate acute illness, but a broader assessment shows that he has lost weight, has difficulty managing medicines and rarely leaves home.
The health team can address cognition, medicines and nutrition. Yet the assessment also reveals that he lives alone and his daughter travels an hour each way to support him several evenings a week.
A purely clinical response might schedule follow-up and refer for specialist assessment. A more integrated response recognizes a wider care situation.
With appropriate consent and local pathways, social assistance can examine social vulnerability, available family support and access to community or home-based services. Rehabilitation may consider whether function can be improved. The daughter may need information and caregiver support.
No one organization needs to own every intervention. What matters is that the overall plan makes responsibilities visible and that somebody notices if referrals do not result in support.
If the man's cognition worsens or the daughter becomes unable to continue, the pathway should adapt rather than waiting for an emergency admission to reveal that the arrangement has collapsed.
The scenario illustrates the central integration principle: one person's needs may require several responses, but those responses should still make sense as one care trajectory.
Referral is the point at which integration often succeeds or fails
Many systems can demonstrate that professionals make referrals. Far fewer can demonstrate reliably what happened after the referral was sent.
For an older person with several needs, an open-loop referral can create apparent coordination without actual continuity. Primary care sends information to social assistance. Social assistance advises the family to contact another service. The family waits. No single organization knows whether the need was eventually met.
Closed-loop referral means more than electronic transmission. It requires enough feedback for the referring service to know whether the receiving service accepted the referral, whether another response was more appropriate and whether urgent risks remain unresolved.
This does not mean every referral needs extensive interagency case management. Most care should remain proportionate to need.
The stronger system identifies which situations require active follow-up: severe functional decline, caregiver breakdown, safeguarding concerns, repeated hospital use or people whose vulnerability makes self-navigation unrealistic.
The referral management and closed-loop follow-up agenda therefore has particular relevance to Brazil's emerging care system. Integration becomes tangible when people stop disappearing between institutional boundaries.
Governance must distinguish referral volume from integration quality
A municipality could increase referrals between SUS and SUAS substantially without improving outcomes. More referrals may even indicate that professionals are unsure which system should respond.
Local governance therefore needs more sophisticated evidence.
Useful indicators include whether referrals are accepted appropriately, how long people wait, how often they are redirected, whether urgent risks are escalated and whether the same households repeatedly move between systems without resolution.
Qualitative information also matters. Families can identify problems that formal metrics miss: having to repeat the same story, receiving contradictory advice or being told repeatedly that a need belongs to another service.
Organizations examining similar cross-system arrangements can use the Governance Maturity Assessment to structure questions about responsibility, escalation and assurance. It is not a Brazilian governmental framework, but it provides a practical method for testing whether shared work has clear ownership rather than relying on goodwill alone.
Hospital discharge exposes the boundary most visibly
Transitions from hospital to community are among the clearest tests of health-social integration.
A hospital determines when acute treatment is complete. But medical stability does not establish whether someone can safely resume everyday life.
An older person may leave hospital weaker, newly incontinent, cognitively unsettled or unable to manage stairs. A family that previously provided occasional support may suddenly be expected to provide personal care several times each day.
SUS has essential responsibilities around discharge, medicines, follow-up and rehabilitation. Social-assistance involvement may become relevant where the person lacks a sustainable support network, experiences social vulnerability or requires services within SUAS's remit.
Family capacity should also be assessed realistically. "Lives with daughter" is not a care plan.
This is why hospital-to-community transitions need governance across the boundary rather than a discharge process focused solely on the institution releasing the person.
Operational scenario: a discharge that requires two systems to act
An 83-year-old woman is medically ready to leave hospital after treatment for pneumonia. Before admission she lived independently in a small apartment. Following ten days in hospital she is weaker, needs help showering and becomes breathless preparing meals.
Her son visits at weekends but cannot provide daily care. The hospital appropriately refers her back to primary healthcare for follow-up and rehabilitation.
During discharge planning, however, it also becomes clear that she has little food at home and has stopped paying several household bills. Her social vulnerability is now as important to the success of discharge as her respiratory recovery.
An integrated pathway enables the health team to connect appropriately with local social assistance rather than simply documenting that she lives alone. CRAS can consider the household's social-protection needs while SUS continues clinical and functional follow-up.
The two systems retain different responsibilities. The primary-care team does not become responsible for income support; CRAS does not manage pneumonia. But the overall transition is governed as one situation.
If her function improves, support may reduce. If she deteriorates or remains unable to perform essential activities, the local system needs to reconsider the level and type of longer-term support required.
The operational gain is not a new institution. It is fewer gaps between existing institutions.
Home-based care is becoming a major integration laboratory
The home is where institutional boundaries often become least meaningful to the person. Healthcare, personal assistance, family support, housing conditions and social vulnerability coexist in the same physical space.
Brazil's existing and emerging home-based programs therefore provide particularly important opportunities for integrated care.
Within SUS, Melhor em Casa provides specialized home healthcare for people whose clinical circumstances meet its criteria. Padi Brasil, established within primary healthcare, extends multidisciplinary support to eligible home-restricted older people and connects with other APS teams and the wider Rede de Atenção à Saúde.
SUAS also includes home-based Basic Social Protection for older and disabled people, focused on social participation, family and community relationships, access to rights and prevention of isolation or rights violations.
These services are complementary, not interchangeable.
The central implementation question is whether local teams understand how to connect them where appropriate. A Padi professional may identify severe caregiver strain or unsafe social circumstances. A SUAS home-based worker may recognize worsening mobility, cognition or symptoms requiring health assessment.
Good integration creates reliable escalation in both directions.
This links directly with the broader home- and community-based services agenda. Supporting someone at home successfully requires a network rather than a single visiting service.
Cuidado em Casa is testing a more explicitly integrated model
Brazil's current policy development includes an important emerging example: the Cuidado em Casa pilot within Brasil que Cuida.
Launched in 2026 with support involving the Inter-American Development Bank and Japan International Cooperation Agency, the initiative is being tested in Fortaleza, Ceará; Colombo, Paraná; and Juazeiro, Bahia.
The pilot is specifically intended to strengthen integration between health and social assistance for older people receiving support at home, while also addressing the needs of unpaid family caregivers.
Its significance lies in the problem it is testing rather than in its current scale. Cuidado em Casa should not be described as an established nationwide long-term care service. It is a pilot whose learning may inform wider policy.
That distinction is important. Brazil already has multiple home-based services, but a future integrated care model needs to determine how multidisciplinary assessment, personal support, caregiver assistance and system coordination can operate together within territorial networks.
The pilot also reflects a broader shift within Brasil que Cuida: home support is increasingly being considered not simply as a health intervention or a private family responsibility, but as part of public care infrastructure.
The strength of the pilot will ultimately depend on evaluation. Which people benefit? What changes for caregivers? Does hospital use change? Do people maintain function? How much workforce is required? Which elements can small municipalities realistically reproduce?
Belo Horizonte provides an important existing reference point
Brazil also has local experience that predates the National Care Policy. Belo Horizonte's Programa Maior Cuidado has attracted federal attention as an example of integration between SUS and SUAS for vulnerable older people.
The model brings health and social-assistance structures together around older people who require support to remain at home, including the use of care workers within an integrated local approach.
Its relevance is not that every municipality should reproduce Belo Horizonte's operating model exactly. Local workforce, financing, geography and service infrastructure differ significantly across Brazil.
The more valuable lesson is that integration can move beyond referral and into shared service design. Rather than health identifying a social problem and transferring responsibility entirely to SUAS, the local system can construct an intervention in which both sectors have defined roles around the same person's outcome.
That experience is particularly useful as the federal government develops newer integrated home-care approaches. Existing municipal practice can inform national policy rather than reform flowing only from Brasília outward.
This illustrates the value of pilot evaluation and learning loops. Strong national development depends on identifying why a local model works, what conditions enable it and which elements are transferable.
Operational scenario: integration prevents caregiver collapse
A 72-year-old woman supports her husband, aged 79, who has Parkinson's disease and increasing difficulty with transfers and personal care. Primary healthcare monitors his condition, but most daily assistance is provided by his wife.
During a home contact, a health professional realizes that the wife has back pain, rarely leaves the house and is increasingly frightened that she will drop her husband during transfers.
The husband's clinical condition is not the only risk. The care arrangement itself is becoming unstable.
A genuinely integrated response considers both people. Rehabilitation may reassess transfer techniques and equipment. Primary healthcare can address the wife's own health. Social assistance can examine whether relevant family, community or home-based support is available within the local network.
Where an integrated care-worker model exists, additional assistance may reduce the physical burden directly.
The important governance question is whether the system records caregiver strain as a relevant determinant of the husband's care sustainability rather than treating his wife simply as an available resource.
This connects with caregiver support and navigation. Integration is strongest when it recognizes that the needs of the person receiving care and the sustainability of the person providing unpaid care are interdependent.
Shared care planning requires clarity about decision rights
Integration can fail when several professionals are involved but nobody understands who is responsible for which decision.
A social worker may identify an unsafe home situation. A nurse may be concerned about medication. Rehabilitation staff may believe the person could regain more independence. Family members may want residential care while the older person wants to remain at home.
Shared care planning therefore requires more than a multidisciplinary meeting. It needs clarity about professional authority, the person's own rights and the decisions that require escalation.
Healthcare decisions remain within appropriate clinical responsibilities. Social-assistance decisions follow SUAS frameworks. The older person's preferences and legal rights remain central rather than being displaced simply because several systems are involved.
Where risks are complex, the integrated plan should make explicit:
- what outcomes matter to the person;
- which needs each service is addressing;
- which risks require active monitoring;
- who will respond if circumstances change;
- when the plan will be reviewed.
This avoids the common problem of "shared responsibility" becoming responsibility that belongs to nobody.
Funding remains one of the hardest integration problems
SUS and SUAS do not simply represent different professional cultures. They have different financing structures and administrative arrangements.
This creates a practical challenge when an integrated model requires a service that does not fit neatly within one existing funding stream.
A care worker supporting an older person at home may reduce caregiver burden, prevent hospital admission and support social participation simultaneously. Which system should pay?
From the person's perspective, the distinction is irrelevant. From the perspective of public administration, it can determine whether the service exists.
Brasil que Cuida creates an opportunity to align investment around care outcomes rather than expecting every innovation to fit unchanged into historical program boundaries.
That does not mean pooling all budgets automatically. Financial accountability remains important. The stronger approach is to identify where separate funding streams create predictable gaps and develop explicit mechanisms for joint or coordinated investment where legally and operationally appropriate.
The experience is relevant to integrated funding pilots, particularly when new care models generate benefits across more than one public system.
Data integration should begin with the decisions that need to improve
It is tempting to treat interoperability as the technical solution to fragmented care. If SUS and SUAS could simply see one another's data, integration might appear straightforward.
The reality is more complex.
Health records contain clinical information. Social-assistance records can contain sensitive information about poverty, family relationships, violence and vulnerability. Not every professional needs access to everything.
The starting point should therefore be the decision that needs to improve.
If a primary-care team needs to know whether a high-risk referral to social assistance resulted in contact, that may require status information rather than unrestricted access to a complete social-assistance file. If CREAS is considering risks affecting a person with dementia, selected information about cognition may be essential while other clinical details remain unnecessary.
This approach aligns integration with privacy and proportionality.
The cross-agency data-sharing and governance agenda is consequently central. Information-sharing arrangements should specify purpose, access, responsibilities and escalation rather than relying on informal exchange.
Organizations developing digital cross-system pathways can also use the Digital Transformation, AI and Cybersecurity Readiness Assessment to test whether governance, cybersecurity and operational processes are ready for greater connectivity. The tool has no formal role within SUS or SUAS, but the underlying discipline is applicable.
Workforce integration depends on capability as much as structure
Formal partnership agreements cannot integrate services if professionals do not understand one another's roles.
Primary-care teams need enough knowledge of SUAS to recognize when CRAS, CREAS or another social-assistance response may be appropriate. Social-assistance professionals need enough understanding of aging, cognition and functional decline to recognize when health assessment is required.
This does not mean turning social workers into clinicians or health workers into social-assistance specialists.
Cross-system capability is about boundaries, referral judgment and shared language.
Multidimensional assessment may help because it creates a common focus on function and vulnerability. Joint learning around safeguarding, caregiver strain, hospital transitions and dementia can also strengthen professional relationships.
Care workers occupy another important position. Emerging integrated home-support models may rely on workers whose activity connects everyday personal assistance with professional health and social-care networks. Training, supervision and escalation therefore matter enormously.
The workforce problem is consequently both quantitative and relational. Brazil needs enough workers, but it also needs teams capable of collaborating without duplicating one another or leaving essential tasks unowned.
Operational scenario: a safeguarding concern tests the integrated pathway
An older woman with mild cognitive impairment attends primary healthcare with bruising on her arm. She says she fell, but appears anxious when her adult grandson answers questions for her.
The clinical team needs to assess the injury and determine whether there are immediate health risks. It also has reason to consider possible abuse or coercion.
Simply referring the case and closing the health episode would be inadequate. Equally, healthcare professionals should not attempt to conduct the entire specialist social-protection response themselves.
Where thresholds are met, CREAS and PAEFI may become relevant within SUAS, alongside other protection mechanisms appropriate to the circumstances.
The older woman's voice remains important. Cognitive impairment does not automatically remove her ability to express wishes or participate in decisions.
The systems also need to consider practical dependency. If the grandson currently provides essential meals or transport, protection planning must consider how those needs will be met if contact changes.
This is where interagency safeguarding coordination becomes a real operational requirement. The risk exists across health, social protection, family care and everyday living, so no single service can resolve it safely in isolation.
Municipal governance is where integration becomes operational
National policy can promote intersectorality, but integration is experienced locally.
Municipalities therefore need governance arrangements capable of looking across primary healthcare, social assistance, home-based services, hospitals, rehabilitation, community organizations and emerging care-policy initiatives.
This does not necessarily require creating a new bureaucracy. Existing structures may be able to perform much of the work if responsibilities are explicit.
The key is visibility. Local leaders need to know whether older people are experiencing recurrent gaps, whether particular transitions repeatedly fail and whether workforce or service shortages are driving avoidable hospital use or family breakdown.
They also need mechanisms for people using services and caregivers to influence planning. Integration viewed only from organizational charts can look much stronger than integration experienced by families.
The Quality Dashboard Builder provides one way to structure multidimensional oversight across access, outcomes, workforce and transitions. It is not an official municipal Brazilian tool, but its value lies in bringing different evidence into one governance conversation rather than allowing each organization to report only its own activity.
Integration should be judged by outcomes that cross institutional boundaries
Traditional performance measures often reinforce fragmentation because organizations report what they control directly.
A hospital reports length of stay. Primary care reports consultations. CRAS reports contacts. A home-care program reports visits.
None of those measures alone shows whether the older person remains safely at home.
Integrated care needs outcomes that cross boundaries. These may include functional stability, successful transition after hospital discharge, reduced caregiver strain, fewer repeated crises, sustained community living and timely resolution of referrals.
Equity also matters. An integrated model that works only in well-resourced urban municipalities does not establish national integration.
Data should therefore be stratified sufficiently to reveal territorial and socioeconomic variation.
When recurring gaps are identified, governance should lead to improvement rather than passive reporting. The Quality Improvement Action Plan Builder can help organizations translate findings into actions, ownership and review. It does not replace Brazilian accountability arrangements, but it supports the principle that integration problems should generate corrective learning.
Brasil que Cuida creates a stronger policy home for integration
Historically, Brazil's health and social-assistance systems developed through their own substantial institutional architectures. Long-term care needs often sat across them without one overarching policy framework explicitly responsible for the relationship.
The Política Nacional de Cuidados changes that context.
Brasil que Cuida explicitly emphasizes intersectoral action and federative coordination. Its voluntary territorial adhesion process is designed to help states, the Federal District and municipalities diagnose local needs and develop care actions aligned with national principles.
The federal government is also providing technical support to participating jurisdictions for local care planning.
This creates an opportunity to treat integration as a care-policy objective rather than relying solely on individual SUS-SUAS relationships developed locally.
However, national policy should not imply that institutional integration has already been achieved. The current landscape includes established local models, new national programs and pilots at different stages of implementation.
The strongest approach is to use this period as an intentional learning phase: evaluate what works, identify the resources required and build mechanisms that can be adapted rather than simply copied across very different territories.
Brazil's international lesson is about building interfaces, not creating a super-system
Many countries struggle with fragmentation between healthcare and long-term social support. Brazil's experience offers an important perspective because it already has two large decentralized systems with strong territorial presence.
The transferable lesson is not that another country should reproduce SUS or SUAS. Their constitutional, financing and professional structures are distinctively Brazilian.
The more useful lesson is that integration does not necessarily require institutional merger. Systems can retain separate mandates while creating stronger interfaces around people whose needs cross those mandates.
A second lesson concerns territorial infrastructure. Integration is easier when professionals are already connected to defined communities rather than working entirely through centralized specialist services.
A third is that caregivers need to be visible within integrated pathways. The sustainability of family care directly affects health and social outcomes.
Finally, pilots matter most when they create transferable learning. Brazil's current integrated home-care initiatives should therefore be judged not only by whether participants benefit, but by what they reveal about workforce, financing, data and governance requirements for wider implementation.
The future is a coordinated care continuum rather than a new institutional boundary
Brazil's aging population will increasingly produce needs that sit between traditional service categories. An older person may not require hospitalization but be unable to manage at home without assistance. Another may have no acute clinical problem but face severe social risk. A third may need rehabilitation, caregiver relief and dementia support simultaneously.
A mature long-term care system needs to respond to those combinations without forcing the person to fit one institution's definition of need.
The future care continuum is therefore likely to rely on stronger primary healthcare, SUAS territorial services, multidisciplinary home care, caregiver support, rehabilitation, day provision, residential services and private or community capacity operating within clearer pathways.
Not every person requires intensive coordination. Integration should be proportionate. The most complex and vulnerable situations need stronger active management, while simpler needs should move through efficient ordinary referral pathways.
The strategic objective is straightforward even if implementation is difficult: institutional boundaries should organize public responsibility without becoming barriers that people and families are expected to navigate alone.
Conclusion
Brazil does not need to choose between SUS and SUAS as the foundation for long-term support. It needs both systems to perform their distinct roles while connecting much more reliably around people whose needs cross health, function, social protection and family life. Universal healthcare can identify and treat illness, preserve function and provide rehabilitation. Social assistance can address vulnerability, relationships, rights and community support. Neither can substitute completely for the other.
The central operational challenge lies in the interface: whether referrals close, whether information moves proportionately, whether hospital discharge connects with the reality of home life, whether caregiver strain becomes visible and whether professionals know who should act when circumstances change.
Current developments provide genuine reasons for cautious optimism. Brasil que Cuida has created a stronger national policy framework for intersectoral care, while local experience such as Programa Maior Cuidado and the emerging Cuidado em Casa pilot are providing practical models from which Brazil can learn. They should nevertheless be treated as evolving approaches rather than evidence of nationwide integration already achieved.
The strongest future direction is not a new super-system absorbing SUS and SUAS. It is a coordinated care continuum in which institutional responsibilities remain clear but the person's pathway becomes coherent. As Brazil ages, that distinction will become increasingly important. Successful integration will ultimately be visible when an older person can move between healthcare, rehabilitation, social protection and long-term support without each transition creating another gap for the family to solve.